
Glass 
Book 



COPYRIGHT DEPOSIT 



THE TREATMENT OF 

GONORRHEA 

AND ITS COMPLICATIONS 

IN MEN AND WOMEN 
FOR THE GENERAL PRACTITIONER 

BY 

7ILLIAM J. ROBINSON, M.D. 

?» 

of the Department of Genito-Urinary Diseases and Dermatology, Bronx 
ital and Dispensary; Editor The American Journal of Urology, Ven- 
A and Sexual Diseases ; Editor of The Critic and Guide ; Author of 
t eatment of Sexual Impotence and Other Sexual Disorders in Men and 
l7 omen ; Sexual Problems of Today ; Never Told Tales ; Practical Eu- 
genics, etc. President of the American Society of Medical Sociology, 
Ex-president of the Berlin Anglo-American Medical Society, 
Fellow of the New York Academy of Medicine, Member of 
American Medical Editors' Association, American Medical 
Association, New York State Medical Society, Interna- 
tionale Gesellschaft fur Sexualforschung, American 
Urological Association, etc., etc. 



1915 
CRITIC AND GUIDE COMPANY 

12 MT. MORRIS PARK WEST 
NEW YORK 



-"SX^ 



^ 

v 



SOME OF 

DR. W. J. ROBINSON'S BOOKS 
AND JOURNALS 

A Practical Treatise on the Causes, 
Symptoms and Treatment of Sex- 
ual Impotence and other Sexual 
Disorders in Men and Women .... $3.00 

Sexual Problems of To-day 2.00 

Never Told Tales 1.00 

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Improving the Human Race 50c. 

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Monthly: $1.00 a year; Single Copies, 20c. 

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Copyright 1915, by 
Critic and Guide Co. 



♦ 

JUN-5I9I5 

HIA406164 



i 



TO 

PROFESSOR ALBERT NEISSER 

WHO BY HIS DISCOVERY OF 

THE GONOCOCCUS, THE SPECIFIC CAUSE OF GONORRHEA, 

HAS RENDERED AN IMMORTAL SERVICE 

TO HUMANITY, 

THIS BOOK IS RESPECTFULLY DEDICATED 

BY THE AUTHOR 



PREFACE 

Some specialists in venereal diseases say that all patients 
afflicted with gonorrhea should go to a specialist for treat- 
ment, and not to a general practitioner. They say that 
the general practitioner is not competent to treat gonor- 
rhea properly. Whether these statements are made by the 
above referred to specialists from purely altruistic motives, 
exclusively out of consideration for the patient's welfare, 
is not a question that needs be discussed here. Of course 
the specialist would be financially benefited; there is no 
doubt about that; but the patient would also be greatly 
benefited, and there would be fewer uncured and incurable 
cases in the land. Be this as it may, granting the desira- 
bility of having every case of gonorrhea treated by a spe- 
cialist, this is a Utopian desire; a hope that will not be 
realized for fifty or a hundred years to come. There are 
not enough gonorrhea specialists in the country to treat all 
the cases of gonorrhea. We are told that next to measles 
gonorrhea is the most widespread disease; and as all cases 
of measles could not be treated by pediatrists, so all cases 
of gonorrhea could not be treated by urologists. And as- 
suming that the number of "gonorrhea" specialists should 
become adequate to the task of handling all cases of gonor- 
rhea — supply generally follows demand — it would be abso- 
lutely impossible for everybody to patronize a specialist: 
their economic condition would not permit it. We forget 

that medicine is greatly influenced by the financial condi- 

7 



8 PREFACE 

tion of the people. And medical treatment will not become 
ideal until a radical change has taken place in our social 
system. And as this is going to take some time, things will 
run the way they have been running for another century 
or two, and ninety per cent, of all men unfortunate enough 
to contract gonorrhea will continue to be treated by the 
general practitioner. And it is therefore our duty to do 
our share to make the general practitioner as competent 
as possible. 

The instruction in venereal and sexual diseases given in 
our medical colleges is disgracefully meager and is re- 
sponsible for the inadequacy of the average general prac- 
titioner in the treatment of these diseases, and for the exist- 
ence of the quack. A good plain treatise on the treatment 
of gonorrhea and its complications, intended specially for 
the general practitioner, seemed to the author as well as 
to numerous readers of his books and journals, a desidera- 
tum. For we have no satisfactory textbooks on gonorrhea. 
We have a number of books on genito-urinary surgery 
which contain chapters on gonorrhea, we have a number of 
quiz compends on venereal diseases, but they are not books 
which answer the demands of the general practitioner. 
The books specially devoted to the treatment of gonorrhea, 
like Wossidlo's, are too technical and are suitable chiefly 
for specialists. The best book on the treatment of gonor- 
rhea so far is Luys ? "Traite de la Blenorrhagie, ' ' but un- 
fortunately his favorite methods of treatment are urethro- 
vesical irrigations and urethroscopy, and to advise the 
physician to treat his cases of gonorrhea with irrigations 
and by the aid of the urethroscope is to do the physician 
and his patients a very poor service indeed. I shudder to 



PREFACE 9 

think of the complications and of the number of incurable 
cases that would result. Even in skilled hands urethro- 
scope treatment is not accomplishing what its zealous 
advocates claim it does; in unskilled and hurried hands, 
as must be those of the physician who treats all other ail- 
ments of the flesh, it would lead to frequent disaster. The 
number of damaged urethras would be too great to be 
counted. Noli nocere is the first requirement of any treat- 
ment which we are recommending to the general practi- 
tioner, and this motto has been well kept in mind through- 
out the book. 

The style of the book is the plain, non-stilted style, which 
the author has used in his "Treatment of Sexual Im- 
potence, ' ' which he uses in his Critic and Guide editorials, 
which he uses in his ordinary conversation. Practically 
the entire book has been dictated right from the head, with- 
out referring to any books. It was considered a fairer way 
,to present the present day status of the successful treat- 
ment of gonorrhea and its complications than by merely 
rehashing a dozen textbooks. It was thought that what a 
specialist with fair abilities and a good memory, who has 
been treating venereal diseases daily for twenty years, 
could not say right off, without reference to books, regard- 
ing gonorrhea or any of its complications, was not worth 
knowing, was not necessary for the general practitioner to 
know. Of course before sending the typewritten manu- 
script to the printer I gave it some finishing touches, but 
the book is distinctly a personal book, and represents how 
Dr. Robinson treats gonorrhea and its complications and 
not how A., B. and C. treat them. This does not mean 
that the author has not read and studied the various text- 



10 PREFACE 

books and papers on gonorrhea; on the contrary, he prob- 
ably read and studied every one of any significance ; but it 
does mean that nothing is represented in this book that has 
not passed through the crucible of his judgment and ex- 
perience. 

The author is convinced that by following the teachings 
of this volume the general practitioner will become much 
more successful in the treatment of his gonorrheal patients 
than he has been in the past. 

W. J. R. 

12 Mt. Morris Park West, New York. 



CONTENTS 



Pkof. Albert Neisser . ' Frontispiece 

chapter page 

Preface 7 

I The Extent and Seriousness of Gonorrhea . . 13 

II The Classification of Urethral Inflammations 18 

III Gonorrheal Urethritis in the Male .... 20 

IV The Germ and the Diagnosis of Gonorrhea. . 23 
V The Course and Symptomatology of Acute Gon- 
orrhea 29 

VI Treatment of Acute Gonorrhea . . . . .35 

VII Case Reports 55 

VIII Common Bacterial Urethritis 61 

IX Chancroidal Urethritis 65 

X Syphilitic or Chancre Urethritis 67 

XI Chemical Urethritis • . . 74 

XII Prophylactic Urethritis 86 

XIII Traumatic Urethritis 88 

XIV Toxic Urethritis . . . . . . . . . .89 

XV Urethritis from Excess and Masturbation . .91 

XVI The Widely Varying Conditions Known as 

Chronic Gonorrhea 93 

XVII The Treatment of Chronic Gonorrhea . . . 97 
XVIII The Length of Time Required to Cure Chronic 

Gonorrheal Conditions 109 

XIX The Instruments Used in the Treatment of 

Gonorrhea 115 

XX The Abortive Treatment of Gonorrhea . . .119 

XXI The Prevention of Gonorrhea 124 

XXII The Minor Complications of Gonorrhea . . .134 

XXIII Acute Prostatitis 146 

XXIV Chronic Prostatitis . . . 154 



CONTENTS 



CHAPTER 

XXV 

XXVI 

XXVII 

XXVIII 

XXIX 

XXX 

XXXI 

XXXII 
XXXIII 
XXXIV 



XXXV 

XXXVI 

XXXVII 

XXXVIII 

XXXIX 

XL 

XLI 

XLII 



PAGE 

Epididymitis 168 

Seminal Vesiculitis 183 

Gonorrheal Proctitis — Gonorrhea of the Rec- 
tum 187 

Gonorrheal Stomatitis — Gonorrhea of the 

Mouth 189 

Stricture 191 

Gonorrheal Arthritis 202 

Gonorrhea vs. Tobacco, Alcohol, and Sexual In- 
tercourse 209 

Gonorrhea in Women 218 

vulvo-vaginitis in little glrls . . . . . . 234 

Gonorrheal Ophthalmia — Gonococcal Infection 
of the Eyeu Ophthalmia Neonatorum. Oph- 
thalmia of the Newborn 243 

Minor Points 251 

Silver Salts — Inorganic and Organic .... 260 
Miscellaneous Antiseptics and Astringents . 267 

Vegetable Astringents 273 

Local Anesthetics 274 

Antigonorrheal Remedies for Internal Use . .277 

Urinary Antiseptics 283 

Lubricants 288 

Formulary 291 

Index 309 



CHAPTER I 
INTRODUCTION 

THE EXTENT AND SERIOUSNESS OF 
GONORRHEA 

I suppose it would be the appropriate thing to start this 
book with a disquisition upon the widespread extent of 
gonorrhea and all the terrible ravages that it works in the 
individual and in the race. Gonorrhea is a widespread 
disease and it does cause great ravages in the individual 
and in the race. Nevertheless neither its extent nor its 
seriousness must be exaggerated. The writer has always 
had a great aversion to lurid exaggerations of any kind: 
first, because an exaggeration is an untruth, or a half-truth, 
which Tennyson declares to be the worst of lies; and sec- 
ond, an exaggeration usually defeats the very object in be- 
half of which it is propagated. 

The exact or even the approximate extent of the preva- 
lence of gonorrhea no living person knows. All figures or 
statements in this respect are pure guesses without any 
solid foundation. We all go by impressions. The general 
practitioner practicing in a small town, who frequently 
does not see a case in ten years (because the patients go 
to neighboring large cities for treatment or are treated by 
their druggist and barber) is apt to minimize the extent 

of venereal disease. The specialist who treats nothing but 

13 



14 GONORRHEA AND ITS COMP LI CATIONS 

gonorrhea is apt to judge of all humanity by his patients, 
and to imagine that everybody has or has had gonorrhea, 
forgetting that after all he sees only a very small percent- 
age of the population, and that the people who are free 
from the disease do not go to him at all and he has there- 
fore no means of knowing whether they have or have not 
the disease. 

I have always been fighting against the specialist's tend- 
ency to exaggeration and strabismus, and I will say right 
at the outset that the statements usually made that eighty 
to ninety per cent, of the male population of every civil- 
ized country have or have had gonorrhea are to me absurd. 
It is the same story of the extreme swinging of the pendu- 
lum in the other direction. For a long time gonorrhea 
was practically disregarded as a disease, and its sequelae 
in the individual, and its dangers to the welfare and life 
of the future wives, were not even dreamed of. Noeg- 
gerath made himself immortal, and deserves the eternal 
gratitude of all womanhood, by calling the attention of 
the profession to latent gonorrhea and its dangers. But 
I am sure that his statement that eighty per cent, of the 
male population has gonorrhea, that ninety per cent, of 
them are never cured, and that they all eventually infect 
their wives was a wild exaggeration. 

I believe that if we say that twenty-five per cent, of the 
male population suffer with gonorrhea at one time or an- 
other, we would rather be overstating than understating the 
truth. Of course its prevalence varies in different strata 
of society. In some of the lower strata it may be as high 
as one hundred per cent., but then on the other hand there 
are several strata of society in which it does not, in my 



SERIOUSNESS OF GONORRHEA 15 

opinion, exist to a greater extent than five or ten per cent. 
As to the curability of this disease I also disagree with 
the somber estimates of the pessimists. Instead of ninety' 
per cent, remaining uncured or being uncurable, I believe 
that the greatest percentage of gonorrheas end in a prac- 
tical cure. I say ''practical" because a good many cases 
may show for many years some shreds in the urine or a 
minute droplet of discharge and still be practically cured, 
that is, free from gonococci and non-dangerous to their 
partners. Naturally, I also disagree with the statement 
as to the frequency with which wives acquire the disease 
innocently from their husbands. According to the state- 
ments of some of our zealous friends practically every 
woman who marries a man who has had gonorrhea acquires 
the disease, and as according to their statements eighty or 
ninety per cent, of men have had gonorrhea at one time or 
another and ninety per cent, of these cases remain uncured, 
practically every married woman would be suffering from 
gonorrhea. Do they know to what absurd conclusions this 
absurd statement leads? The race would have become 
practically extinct if the statements just referred to were 
true. Fortunately they are not. As is well known, Prof. 
Erb's investigation in his private practice led him to the 
conclusion that only four per cent, of women who married 
husbands who had had gonorrhea contracted the disease. 
Allowing for the fact that his practice was among the well 
to do, who can afford skillful, prolonged and painstaking 
treatment, we would be justified in stating that about ten 
per cent, of married women acquire the disease innocently, 
a high enough figure as it is, enough to terrify us without 
any exaggerations! Exaggeration and painting in lurid 



16 GONORRHEA AND ITS COMPLICATIONS 

colors may be permissible for propaganda purposes, but 
they should be frowned upon by scientists whose only func- 
tion is to tell the truth. 

SERIOUSNESS OF GONORRHEA 

Gonorrhea is a serious disease, serious to the individual 
male, potentially serious to his wife and to his children. 
But even here we must not exaggerate. One writer says 
we must tell our young men that gonorrhea may end in 
death. But so may measles, so may a pinprick, so may the 
paring of a corn or the extraction of a tooth. It is all a 
matter of the frequency of such an eventuality. It is true 
that gonorrhea may end in an endocarditis or a general 
septicemia leading to death, but these results, are extremely 
rare, and we gain nothing by using these possible but ex- 
tremely rare sequelae as specters to frighten our young 
men. In the vast majority of cases gonorrhea is a per- 
fectly curable disease, leaving few or no sequelae. 

Gonorrhea is a serious and dangerous disease, but its 
seriousness and dangerousness do not reside in the gonor- 
rhea per se, but in our social-economic conditions, which 
do not permit the individual the proper rest and the proper 
treatment. If our patients attacked with gonorrhea could 
at once obtain the same care and treatment as do patients 
attacked with typhoid fever or pneumonia, ninety per cent, 
of them would be perfectly well by the end of two or three 
weeks. 

But because gonorrhea is a " shameful " disease, because 
the young man must hide its existence from his parents, 
because there are no hospitals which accept venereal pa- 
tients, because the patient must keep on working, perhaps 



SERIOUSNESS OF GONORRHEA 17 

running up and down stairs and lifting heavy weights, be- 
cause he is unable to go to skillful specialists, but is obliged 
to treat himself with nostrums or be treated by the hurried 
and not always competent general practitioner, or in the 
frequently worse than useless dispensaries ; because of these 
things gonorrhea becomes in many cases such a serious dis- 
ease, dangerous to the individual himself (arthritis, endo- 
carditis, etc.), to his wife (endometritis, salpingitis, ovari- 
tis), to the child (ophthalmia neonatorum) and by his be- 
coming sterile or by rendering the wife sterile, to the race. 
To emphasize and to recapitulate: Skillfully treated 
from the beginning, under proper hygienic and dietetic 
conditions, gonorrhea is a benign affection; neglected or 
maltreated gonorrhea becomes an intensely dangerous dis- 
ease. Which again brings us to the point emphasized by 
the author so many times, that if we wish to be successful 
in the treatment of our patients we must demand an im- 
provement or a radical change in the social-economic condi- 
tions of the people. 



CHAPTER II 

THE CLASSIFICATION OF URETHRAL 
INFLAMMATIONS 

Urethritis is an inflammation of the urethra accompanied 
by pain, swelling and discharge. Not all urethral dis- 
charges and inflammations are due to the gonococcus. Of 
course gonorrhea is so much more frequent and serious that 
it overshadows all other urethral troubles. Nevertheless 
if we wish to avoid blunders, blunders which may prove 
extremely serious to the patient, we must bear in mind 
that a discharge from the urethra may be of other than 
gonococcal origin, and I therefore give at the outset a 
classification of urethral inflammations. Bearing this clas- 
sification in mind may help one to avoid gross errors in 
diagnosis. 

We divide them first into two large classes: 

I. Bacterial. 

II. Non-bacterial. 

In the bacterial class we have the following varieties: 

1. Gonococcal or Gonorrheal; 

2. Common or simple bacterial; 

3. Chancroidal; 

4. Syphilitic; 

5. Tubercular; 

6. Neoplastic (?) 

The non-bacterial or aseptic urethrites may be classified 

as follows: 

18 



CLASSIFICATION 19 

7. Chemical; 

8. Traumatic; 

9. Toxic; 

10. Diathesic. 

To class urethrorrhea among the urethrites is incorrect, 
for urethrorrhea can hardly be considered an inflamma- 
tion of the urethra. Still more incorrect and utterly with- 
out excuse is to class prostatorrhea and so-called sperma- 
torrhea among the urethrites. 



CHAPTER III 
GONORRHEAL URETHRITIS IN THE MALE 

Gonorrhea or gonorrheal urethritis is an inflammation of 
the urethra caused by a germ which was discovered by 
Neisser in 1879 and named by him the gonococcus, or the 
gonococcus of Neisser. 

Taking the word gonorrhea in its pre-Neisserian sense, 
as synonymous with urethral discharge, the disease is one 
of the oldest known. It is mentioned in the Bible, and it 
has been described by Greek and Roman writers. Of 
course we have no means of knowing whether the urethral 
discharge spoken of by the ancients was specific in char- 
acter and due to the gonococcus, or whether it was due to 
some other germ, or altogether non-bacterial; but we are 
justified in assuming that at that time, the same as now, 
most of the cases were due to the gonococcus. The de- 
scription given by the ancients tallies very well with our 
gonorrhea. 

The etymology of the word gonorrhea is barbarous in the 
extreme, if we consider its significance. Literally it means 
a running of semen, from : gonos=&emen and rheo=I run. 
The ancients thought that the urethral discharge was due 
to running out of spoiled, poisoned semen. We know bet- 
ter, but all attempts to change the word have proved and 
will prove fruitless. It is difficult or impossible to change 

an incorrect but thoroughly established word for one sci- 

20 



GONORRHEAL URETHRITIS 21 

entifically correct. Nor is it necessary. Language was 
made for man, not man for language, and as long as the 
word stands for something definite and gives rise to no con- 
fusion in anybody's mind, it is a good word, and all at- 
tempts to change it must prove quixotic. The name which 
Neisser gave to the specific germ of gonorrhea is not any 
better, for what does gonococcus mean? It means sernen- 
coccus, which is of course absurd. But we know what it 
stands for, and it is useless to attempt to change it. 
'Gonorrheal urethritis " or "gonococcal urethritis" are 
not much better, nor are the terms blenorrhea and Menor- 
rhagia, used in Germany and France respectively, a great 
improvement. We will therefore adhere to the old term 
gonorrhea, it being understood that when we use the term 
without any other qualification, we refer to an inflamma- 
tion of the urethra caused by the diplococcus of Neisser. 
When speaking of the complications we will use gonorrheal 
prostatitis, gonorrheal epididymitis, gonorrheal vesiculitis, 
etc. 

The infection takes place almost exclusively during sexual 
intercourse. But note that I said almost. I do not at all 
deny the possibility of non-venereal infection, from soiled 
linen or infected instruments; and it will not do to sneer 
at the possibility of infection from a bathtub or the seat 
of a water-closet. In a Berlin clinic I watched an acutely 
gonorrheal patient go into a privy. When he got up there 
was about half a teaspoonful of thick creamy pus on the 
seat, at the point touched by the meatus. A person sitting 
down on that seat within an hour or two would be very apt 
to get some of the pus transferred to his urethra and to 
develop a gonorrheal urethritis. That gonorrheal vulvo- 



22 GONORRHEA AND ITS COMPLICATIONS 

vaginitis in little girls — which however seems to be of a 
different character from the gonorrhea of adults — may and 
often does assume the character of an epidemic, the infec- 
tion being carried by soiled linen, by the nurses, etc., and 
is often contracted in the water-closets of the school, is of 
course well known. 

But the histories of my patients alone would be sufficient 
to make me refrain from being dogmatic about the non- 
possibility of extra-venereal gonorrheal infection. As I 
stated elsewhere, I know that my patients do not lie to me ; 
they certainly do not all lie. They know that I am not a 
hypocrite, that I am not going to pass sanctimonious judg- 
ment upon them, and they have no reason whatever to lie 
about the manner in which they acquired their gonorrhea or 
syphilis. They also fear that deceiving the doctor about 
any detail in their history may lead to different treatment 
and that thus they may not be benefited or may even be 
injured. When, therefore, an intelligent patient assures 
me that he had never had sexual intercourse, or had not 
had any for several months, that he knows no cause for his 
urethral discharge, which shows the presence of gonococci, 
except perhaps that he visited a toilet in a railway or sub- 
way station, or slept in a second rate hotel in which the 
bedding was not of immaculate purity, I see no reason 
whatever for doubting his — or her — story. 

Of course the eases of extra-venereal gonorrheal infec- 
tion are few in number in comparison with those contracted 
during sexual intercourse; but it is important that their 
possibility be not denied altogether. Admitting their pos- 
sibility may prevent unjust accusations, and occasionally 
the breaking up of a home. 



CHAPTER IV 

THE GERM AND THE DIAGNOSIS OF 
GONORRHEA 

The gonococcus, the little germ or micro-organism which 
is responsible for so much human misery, is exclusively a 
human parasite. It can live and thrive in the human body 
only. All attempts to inoculate the gonococcus in any ani- 
mal have failed ; no animal can be infected with gonorrhea. 
Perhaps it was sent to the human race to keep it from 
promiscuity. It is about half the size of a red blood cor- 
puscle, about 1-50 fi in length and 0.7 /x in width. It is a 
diplococcus, that is, it occurs always in twos or in multiples 
of twos. This is due to its method of division. Under the 
microscope in good preparations they appear like a coffee- 
bean which has been opened and laid out flat. They are 
found both in the cells and outside of the cells, and we 
speak of them as extra-cellular and intracellular, but the 
intracellular position is the characteristic one, and a micro- 
scopic specimen which contains many extra-cellular but 
no intracellular cocci would not be typical and would not 
give us the right to make the diagnosis gonorrhea. 

It stains readily with the ordinary basic anilin dyes, such 

as methylene blue, bismarck brown, methyl violet, saffronin, 

fuchsin, etc., and if the smear is properly prepared can be 

easily identified under the microscope. Numerous stains 

have been invented, giving us very pretty microscopic speci- 

23 



24 GONORRHEA AND ITS COMPLICATIONS 

mens, but the general practitioner needs know but one or 
at most two stains, and if he only learns to apply them 
properly he will get for every practical purpose results as 
good as does the expert bacteriologist with the very com- 
plicated and refined stains. But the smear must be pre- 
pared properly. 

HOW TO PREPARE A PROPER SMEAR 

One of the common errors to which the beginner is liable 
is to make the smear too thick. This is an error which must 
be guarded against ; the thinner the layer of pus the better. 
Take a clean glass slide, take a wooden stick or a toothpick 
and wind around it a small wisp of cotton, dip the cotton 
in sterile water and shake off the excess. If the pus is 
gushing from the urethra, wipe off the meatus with some 
cotton or wash it off with sterile water to prevent con- 
tamination with germs which may abound on the glans and 
meatus. Insert the cotton carrier into the fossa navicu- 
laris, and with the pus thus obtained make several narrow 
smears over the glass slide. This distributes the pus very 
evenly and very thinly, and for this reason I prefer this 
method to the platinum loop or to squeezing the pus be- 
tween two slides. Where the pus is very scanty and we 
have to go deep into the urethra to obtain some, there the 
platinum loop may be used. We then allow the thin layer 
of pus to dry on the slide, which takes a minute or two, 
then pass it three times lightly and quickly over the flame 
of an alcohol lamp or Bunsen burner. This fixes the 
preparation. With a glass dropper we then drop one or 
two or three drops of Loeffler's solution of methylene blue, 
allow it to remain two minutes, then wash off in running 




ACUTE GONORRHEAL URETHRITIS 




NON-GONORRHEAL URETHRITIS 



DIAGNOSIS OF GONORRHEA 25 

water. We then dry it with blotting paper (this step may 
be left off) put on a cover glass, put a drop of cedar oil in 
the center of the cover glass, and examine with a 1-12 oil 
immersion lens. And if the typical diplococci are present, 
the patient presents the ordinary history and symptoma- 
tology of gonorrhea, the diagnosis is settled and no further 
investigations are necessary. 

We hear of the danger of making a diagnosis of gonor- 
rhea by the microscope alone, of the possibility of confus- 
ing gonococci with the pseudo-gonococci and the micrococ- 
cus catarrhalis, etc., but these are all academic points, and 
in the vastest majority of cases the general practitioner 
will not be confronted with them. The general practi- 
tioner can never hope to become an expert bacteriologist, 
and where a medico-legal question comes up, or where a 
man wants a final authoritative judgment as to his com- 
plete cure and permissibility to enter matrimony, the de- 
cision will have to be put into the hands of a specialist. 

In the vast majority of cases the patient comes to the 
doctor with unmistakable signs and symptoms of urethri- 
tis. The decision to be made then is only: Is it a gonor- 
rheal or a non-gonorrheal urethritis? — and to decide that 
question the methylene blue test is sufficient in the vast 
majority of cases. 

It occasionally happens that either because the gonococci 
have undergone a degenerative morphologic change, or on 
account of contamination with other germs, it is impossible 
to decide definitely whether the cocci that we see in the 
field are gonococci or not. In such a case we must use the 
well known Gram stain, which was elaborated for us by 
Roux of the Pasteur Institute. 



26 GONORRHEA AND ITS COMPLICATIONS 

Germs can be divided, according to the manner in which 
they behave toward the Gram stain, into Gram-positive and 
Gram-negative. The Gram-positive take the Gram stain 
and are stained by it a deep bine-black. The Gram-nega- 
tive do not take the Gram stain, or if they have been stained 
by some of the anilin dyes are decolorized by the procedure 
involved in making the Gram test. The gonococcus is a 
Gram-negative germ. So then if we stain a specimen with 
one of the anilin dyes, examine it under the microscope 
and see clearly a number of cocci, then we subject the 
specimen to the Gram stain, and examine again the speci- 
men under the microscope and find that the cocci have be- 
come decolorized, we know that we have to deal with gon- 
ococci, while if the cocci which we saw before remain 
stained they are not gonococci. 

The Gram test is performed as follows. Prepare and fix 
the slide as before, pour over it some anilin-water-gentian- 
violet dye and leave on for two minutes, then shake off the 
excess and dip in Lugol's solution. Now dip the slide in 
absolute alcohol. This decolorizes the gonococci. If we 
examine the specimen at this stage we will find that the 
Gram-positive cocci, if there are any there, are of a blue- 
black color, while the gonococci have disappeared from the 
field, so to say, for being unstained they can be seen but 
with difficulty. If we wish, however, we can use a double 
stain, and after removing the slide from the absolute alco- 
hol we dip it in or pour over it some bismarck brown solu- 
tion. Examining the specimen then, the gonococci will ap- 
pear of a light brownish color, while the pseudo-gonococci 
will be blue-black. 



DIAGNOSIS OF GONOKRHEA 27 

CULTURES 

The gonococcus is a difficult germ to cultivate. It does 
not grow on ordinary culture media, such as agar-agar, 
glycerin-gelatin, etc. The medium must contain some 
human serum, blood serum, ascitic fluid, etc. The general 
practitioner cannot possess the facilities nor can he acquire 
the skill necessary for making cultures of gonococci. Nor 
is the procedure of very much use. We often hear it 
stated by some genito-urinary specialists that we cannot 
make a diagnosis of gonorrhea from microscopic examina- 
tions alone, that we must always make a culture. This is 
a fatuous statement, often made I fear for the sake of per- 
sonal aggrandizement. And again, first of all, even a prop- 
erly made culture in the hands of an expert bacteriologist 
is not absolutely conclusive evidence, errors can occur even 
there. Second, the cultures as made by the average labora- 
tory are very often worse than useless, because misleading. 
Thirds the cases where with the history, clinical symptoms, 
and bacteriological findings we are unable to make our 
diagnosis, are so rare as to be negligible. In over twenty 
years' practice, treating patients with I believe a fair de- 
gree of intelligence and success, I have not found it neces- 
sary once to have recourse to a culture. Fourth, it is not 
so important. I mean just what I say, that the differen- 
tial diagnosis between the gonococcus and some other coccus 
is not such a life and death matter as some of our con- 
freres would unwittingly make us believe. One would 
think that the gonococcus is the only deadly bacillus and 
that if the symptoms of which the patient complains are 
due to some other germ the case is of no importance. This 



28 GONORRHEA AND ITS COMPLICATIONS 

is far from being true. Other bacteria flourishing in the 
urethra may give rise to as much trouble as the gonococcus. 
We can have very severe epididymitis, prostatitis, or vesic- 
ulitis from the coli bacillus, staphylococcus, etc.; and 
cystitis, pyelitis, and pyelonephritis are much more apt to 
follow infection by other germs than they are to be the re- 
sult of gonococcal infection. So what's the difference? 
"Whether the urethritis and its various complications are 
due to the gonococcus or to other germs they have to be 
treated, and the treatment is practically the same what- 
ever the infecting agent is. Fifth, the complement fixa- 
tion test is more reliable, gives us more information, takes 
less time and is less troublesome to perform. The comple- 
ment fixation test, similar to the Wassermann test for 
syphilis, is now performed by all serologic laboratories. All 
the general practitioner has to do is to draw a dram or 
two of blood from one of the veins in the elbow, put it in 
a sterilized bottle and send it to the laboratory. 



CHAPTER V 

THE COURSE AND SYMPTOMATOLOGY OF 
ACUTE GONORRHEA 

The course of acute gonorrhea, or more specifically speak- 
ing, acute gonorrheal urethritis in the male may be divided 
into five stages: (1) the stage of incubation, (2) pro- 
dromal, (3) acute or ascending, (4) subacute or stationary, 
and (5) declining or subsiding stage. 

The stage of incubation is the period from the moment 
of infection to the moment of the appearance of subjective 
symptoms. When the gonococci get into the urethra they 
do not cause symptoms at once (it would be better if they 
did) . It takes them some time to ' ' settle down, ' ' to increase 
and multiply, to get into and between the epithelial cells 
of the urethral mucous membrane, and cause inflam- 
matory symptoms. The time required for this develop- 
ment, in other words the length of the incubation stage r 
varies in different cases; but the usual length is between 
three to five days. In other words it takes three to five days 
from the moment of an infectious intercourse until the 
patient becomes aware that there is anything the matter 
with him. During that time the patient is perfectly well. 
The incubation stage may only last twelve hours, and may 
last as long as two weeks; but this is exceptional. The 
shortest incubation stage in my personal experience was 
twenty-four hours, the longest twelve days. The re- 

29 



30 GONORRHEA AND ITS COMPLICATIONS 

ported incubation stages of four to eight weeks may be 
taken with a grain of salt. Or perhaps it is possible that 
the gonococci are deposited on the glans under the prepuce, 
and only later on, after several weeks, become accidentally 
transported to the urethra. At any rate, it is well to re- 
member that in the vast majority of cases of gonorrhea 
the incubation stage lasts from three to five days; the less 
common, but still not excessively rare, limits are: one to 
seven days. 

At the end of this period the patient becomes aware of 
some peculiar sensation in the urethra — the prodromal 
stage commences. The patient feels a little tickling or 
burning in the urethra, particularly in the neighborhood 
of the fossa navicularis — where the gonococci generally 
settle down. If he looks at his penis he finds that the lips 
of the meatus are a little puffed, edematous and red; they 
may be slightly stuck together; but there is no discharge. 
If the patient is told to urinate, the urine is found clear. 
This stage lasts from about twelve to forty-eight hours, and 
the acute stage is before us. Then the most prominent 
symptom of gonorrhea, the discharge — which the patient has 
been fearing and hoping against hope would not come — 
makes its appearance. At first it is scanty, and almost a 
pure white ; gradually it increases in amount, becomes very 
profuse, running almost continually and bathing the glans 
and prepuce, and assumes a yellowish, then greenish yellow 
color. The symptoms keep getting worse (unless checked 
by rational treatment). The lips of the meatus may be 
slightly eroded; the glans and the prepuce are somewhat 
red and swollen; the entire urethra, particularly the fossa 
navicularis, is sensitive and painful ; the act of micturition 






COURSE AND SYMPTOMATOLOGY 31 

is painful, the urine causing a burning sensation, so that 
the patient abstains from urinating as long as possible; 
the entire penis may feel hot and turgid, and painful erec- 
tions are not uncommon. If the patient urinates in two 
glasses, the first one is very turbid, but the second one is 
clear. This acute or ascending stage lasts from seven to 
ten days, when a stationary period lasting from one to two 
weeks supervenes. The discharge is less profuse, urination 
is less painful, but things remain in statu quo, without 
much change until the last, the declining stage. In this 
stage the symptoms abate rapidly, the discharge diminishes 
gradually, until there is but a scanty drop, and this also 
gradually disappears, until in two or three weeks — that is 
at the end of five or six weeks from the appearance of the 
first symptoms, the gonorrhea is completely cured. There 
is no discharge, the urine is perfectly clear, and no gono- 
cocci can be found. 

The above is a faithful description of an average case of 
acute anterior urethritis; but where the inflammation ex- 
tends to the posterior urethra, which is the case in the vast 
majority of instances, two other symptoms become promi- 
nent and cause great annoyance. These two symptoms are 
strangury, a strong desire to urinate every few minutes 
during the day (and several times during the night), and 
severe pain at the end of micturition. While in the course 
of anterior urethritis the act of micturition causes pain, 
it is not so intense, and is more of a scalding or burning sen- 
sation; here the pain, particularly while passing the last 
few drops, is very intense ; the patient often grits his teeth, 
and a cold sweat bathes his forehead and body. 

If the gonorrheal inflammation could be kept limited to 



32 GONORRHEA AND ITS COMPLICATIONS 

the anterior urethra, gonorrhea would be indeed if not a 
trifling, at least not a very serious disease. It is the ad- 
vancing of the inflammation to the posterior urethra that 
renders gonorrhea one of the most annoying diseases we 
have to deal with. For it is through the inflammation of 
the posterior urethra that we get prostatitis, vesiculitis, 
deferentitis, epididymitis and cystitis, and the rarer but 
more serious renal, arthritic and cardiac complications. 

I gave the symptomatology of a case of gonorrheal ure- 
thritis of average severity. There are various gradations 
however, from extremely acute or superacute to very mild 
or subacute. 

SUPERACUTE GONORRHEAL URETHRITIS 

Whether due to a special virulence of the gonococci, to 
an excessive dose of them, to a special susceptibility of the 
patient, or to the fact that he had indulged in an alcoholic 
debauch prior to the sexual one, some cases of gonorrhea 
pursue a violent stormy character from the very beginning. 
After a short incubation stage, with practically no pro- 
dromal symptoms, there starts a profuse greenish discharge, 
often mixed with blood, the entire penis is hot and swollen, 
the meatus is excoriated and everted, the prepuce is in- 
flamed and becomes either phymotic or paraphymotic, the 
acid discharge corrodes the glans, which becomes balanitic, 
urination is excruciatingly painful, the act of urination 
being followed by a few drops of blood, there are painful 
erections and chordee, and there are almost nightly pollu- 
tions, which are also excruciatingly painful, the semen 
being mixed with pus and blood. Besides these local symp- 
toms, the patient's general condition is decidedly affected. 



COURSE AND SYMPTOMATOLOGY 33 

There may be fever, there is a general feeling of malaise, 
headache, chilliness ; there is loss of appetite and the sleep 
is disturbed. Whether due to the loss of appetite and 
sleep or to action of the gonorrheal toxin circulating in 
the blood, the patient may lose several pounds of flesh and 
become pronouncedly anemic in a very short time. 

Strange to say, these violent, superacute cases, if serious 
complications have not set in, often end rapidly in perfect 
recoveries. How to account for it? I account for it by 
the fact that people having this kind of gonorrhea do not 
temporize and do not go about their business. Their in- 
tense suffering forces them to stay at home and to call in 
at once the aid of a competent physician. 

SUBACUTE OR MILD GONORRHEAL URETHRITIS 

The opposite of the picture presented by superacute 
urethritis is presented by this variety. A few days after 
intercourse the patient notices a little tickling or burning in 
the urethra, or these symptoms may be altogether absent. 
Then he notices a little discharge; it is slight in amount, and 
the act of urination causes him no trouble whatever; nor 
does he suffer from erections, chordee, etc. In fact he says 
that but for the slight discharge he would not know that 
there was anything the matter with him. These are the 
mild cases which the patient often neglects, with the result 
that they often terminate in chronic gonorrhea or gleet, or 
through some imprudence on the part of the patient — he 
does not think that he is sick enough to follow a strict 
regime — they become converted into the acute or even super- 
acute variety. 

The mild or subacute variety of gonorrhea is not fre- 



34 GONORRHEA AND ITS COMPLICATIONS 

qucnt — as a first attack. It is seen generally in people 
who have already had one or more attacks of . gonorrhea. 
And it is sometimes difficult or impossible to determine 
whether we have to deal with a fresh infection or with an 
exacerbation of an old dormant apparently cured gonor- 
rhea. 



CHAPTER VI 
TREATMENT OF ACUTE GONORRHEA 



ic- 



: Will you please describe briefly your method of treat- 
ing gonorrhea?" I do not know how many times I re- 
ceived this request within the last ten years from physicians 
throughout the country, who knew or thought that I had 
more than average success in treating this disease. It is 
a perfectly legitimate and excusable frailty of the human 
mind to desire short cuts to knowledge and to successful 
practice. Alas, there are no short cuts, and the knowledge 
and experience acquired in twenty years' study and prac- 
tice cannot be transmitted wholly in a brief article, chapter 
or even book, though suggestions can be offered which will 
help the student on the right road, so that he may also in due 
time become an expert. 

I might make the paradoxical remark that the reason 
my method of treating gonorrhea is perhaps more than 
usually successful is because I have no method, or rather 
I have not one method, I have a hundred methods. No 
two cases of gonorrhea are exactly alike, and I know of 
no disease in which it is so necessary to mix brains with 
your medicines as it is in the treatment of gonorrheal 
urethritis. 

And for this reason, because no two cases of gonorrhea 

are exactly alike, it is so difficult to outline briefly the 

35 



36 GONORRHEA AND ITS COMPLICATIONS 

proper method of treatment. It is easy enough to do it 
provided you can be sure that the physician who follows it 
will use common sense and judgment, will watch the reac- 
tion produced by the treatment, diminishing or increasing 
the strength for instance of the various injections, pro- 
longing or shortening the intervals of their administration, 
or suspending treatment altogether. Nevertheless it has to 
be done. There is a more or less average norm, and I will 
therefore proceed to describe the treatment of a case of 
average severity, reserving special remarks for the excep- 
tionally acute cases on the one hand and the very mild 
cases on the other. 

The treatment of gonorrhea is generally divided into 
general, internal and local, because all three lines of treat- 
ment are necessary for its successful treatment. 

GENERAL MEASURES 

The general measures may be expressed in the words 
"taking things easy." If the patient can afford it he 
should stay home, but under our present economic and 
social conditions there is hardly one man in a hundred 
who can stay home because he contracted gonorrhea. He 
would risk losing his job, his position, or he would "give 
away" his trouble to his parents or his wife, which is just 
as bad. So we have to do the best we can. We therefore 
tell him he should stand as little as possible, walk as little 
as possible, even ride as little as possible, and to recline as 
much as possible. He should be particularly careful about 
lifting things, as by doing so he may invite an epididymitis. 
That he should avoid dancing, horseback riding, bicycling, 



TREATMENT OF ACUTE GONORRHEA 37 

goes without saying, but it is not so well known that rail- 
road and automobile traveling may and often does exert a 
very injurious effect on an acute gonorrhea. 

Sexual Rest. Sexual intercourse is to be strictly pro- 
hibited, and no exceptions are to be made to this rule. One 
might think that this is a point on which it is not necessary 
to spend any time, but those who think so do not know 
mankind as well as I do. I personally have seen many 
cases in my practice where the man did have sexual rela- 
tions during the acute stage of an acute gonorrheal urethri- 
tis. Some did it just because they were vicious brutes, 
some did it because they were married men and were 
afraid to "give themselves away" to their wives. These 
latter used condoms. But whether with or without any 
preventives, intercourse in the acute stage of gonorrhea is 
pernicious, and all those patients had their cases aggra- 
vated, developing a posterior urethritis or a prostatitis, or 
both, where none existed before. 

Diet. The diet should be moderate, and that is about all. 
I do not see the necessity of limiting the patient to a strict 
diet as some of our other urologists do. They may follow 
their usual diet, merely taking care to leave out all spices, 
condiments and salty or acid articles of food. Meat is not 
injurious, though it is better to eat of it sparingly. 

Beverages. All alcoholics of whatever nature are 
strictly prohibited. I do not take any of the statements of 
our older writers for granted, but that alcoholics are in- 
jurious in an acute gonorrhea I have convinced myself 
many times. Coffee is also best cut out because it has an 
irritating effect on the sexual organs, but weak tea may be 



38 GONORRHEA AND ITS COMPLICATIONS 

drunk freely. The best thing to drink during an acute 
gonorrhea is milk, buttermilk, and plenty of plain water. 
Those who do not like plain water may drink a mild al- 
kaline mineral water. Carbonated beverages, however, 
should be avoided, except in small quantities. 

Smoking is perfectly permissible. 

Among the other general measures it is only necessary 
to mention two: the patient's bowels and bath. The pa- 
tient must see to it, or the doctor must see for him, that he 
does not get constipated. A constipated bowel has a bad 
effect on an acute gonorrhea. It has a bad effect for two 
reasons, both because it increases the general toxemia of 
the system, and because mechanically, by the feces press- 
ing on the prostate and the patient straining during defeca- 
tion, the inflammation is aggravated. 

Hot baths are very useful, and they should be taken as 
sitz baths or hip baths. I am afraid of a gonorrheal patient 
taking a full bath. I always fear that some of the pus, 
minute as the amount may be, may be washed off the 
urethra and reach his eyes. 

That the patient should wash his hands each time after 
touching his penis and that the danger of transmitting the 
pus from the urethra to the eyes should be thoroughly em- 
phasized to him 7 also goes without saying. 

It sometimes happens, however, that the physician, either 
because he is very busy, with an office full of patients wait- 
ing, or for other reasons, forgets to give the patient some 
very necessary, some vital instructions. It is therefore a 
good idea to have a printed leaflet which contains the nec- 
essary instructions, and to give it to each patient. It not 
only avoids th£ danger of forgetting, but it saves time. 



TREATMENT OF ACUTE GONORRHEA 39 

For many years I have been in the habit of giving each 
patient with acute gonorrhea the following leaflet : 

PERSONAL INSTRUCTIONS 

AND SUGGESTIONS 

William J. Robinson, M.D. 
12 Mount Morris Park West 

NEW YORK 

1. Uncomplicated gonorrhea is a comparatively mild disease, and 
can be quickly (3 to 6 weeks) and permanently cured. 

2. The disease is, however, very apt to cause complications, and 
then it becomes one of the most difficult and tedious diseases to 
treat. The prostate, bladder, kidneys, joints, heart, may become 
infected. In fact, there is hardly an organ in the body which may 
not become infected with the germ of gonorrhea (gonococcus) or 
its poison ( gonotoxin ) . 

3. Do not believe in any stories of 3 and 5 day cures. If a 
gonorrhea was ever cured in three or five days, it wasn't a gonorrhea. 
It was probably a catarrh of the urethra. 

4. The gonorrheal discharge or pus is fearfully contagious, and 
you must observe the most scrupulous cleanliness. Bringing the 
discharge in contact with your eyes may cost you your eyesight. 
After the slightest contact wash your fingers in the antiseptic so- 
lution I gave you. 

5. Always urinate before injecting. If you are unable to urinate 
at a certain given time, then don't inject. Wait. 

6. After urinating, and before injecting, wash the glans and the 
meatus with a piece of gauze or cotton dipped in the antiseptic 
solution. 

7. Keep the syringe scrupulously clean. The tip should be kept 
in the antiseptic solution all the time. 

8. If you follow the instructions that I gave you, you cannot 
inject too often. If you can inject every hour, do so. If you can- 
not inject so often, then inject as often as you can. 

9. If I ordered for you two or three different injections, then it 
is preferable to get two or three syringes, keeping one for each 
injection. 

10. If your case is an acute one, then you must cut off alcoholic 



40 GONORRHEA AND ITS COMPLICATIONS 

liquors of whatever character absolutely. Tea and coffee and car- 
bonated waters are also best left off. Very weak cold tea is not 
injurious. 

11. I have no objection to your smoking. Smoke as much as you 
want to. 

12. Drink plenty of milk, water, flax-seed tea, etc. The oftener 
you urinate the better, for the urethral canal is flushed and the pus 
is not allowed to accumulate. But do not drink much after 7 p. m., 
as the distension of the bladder during the night with urine is apt 
to cause irritation and chordee. 

13. Do not allow yourself to go constipated. If you are, say so, 
and a mild laxative will be given you. 

14. Eat little and only mild, unseasoned foods. Avoid staying 
up late, and eat nothing for three or four hours before going to bed. 

15. The last injection should be made after the last urination, 
immediately before going to bed. Do not sleep on your back; sleep 
on your side, preferably the right side. 

16. Walk and stand as little as you possibly can. The semi- 
reclining position is the best. Bicycling, horseback riding, dancing, 
etc., are of course very injurious. 

17. It should not be necessary to state that intercourse during 
an acute gonorrhea is criminal folly. Still I have found by experi- 
ence that this admonition is not superfluous. 

18. The cessation of the discharge does not necessarily signify 
that the disease has been radically cured. There may be no dis- 
charge whatsoever and still numerous gonococci may be lurking in 
the submucous tissue, in the little glands and follicles, in the pros- 
tate, etc., and may be awakened to renewed activity at the first 
intercourse or the first glass of beer. You are not cured until you 
have been pronounced cured by a competent authority; and this 
can only be done after two or three thorough examinations, with the 
aid of the microscope, complement test, etc. 

19. Do not get married until permission has been given you by a 
competent authority, after a thorough, painstaking examination. 

20. If your physician is not enjoying your fullest and most abso- 
lute confidence, change him, and the sooner you do it the better. 
It is unfair to yourself and to him to pursue treatment in a half- 
hearted manner. 



TREATMENT OF ACUTE GONORRHEA 41 

INTERNAL TREATMENT 

It is said that there are some urologists who pride them- 
selves on treating acute gonorrhea without any internal 
medicine, particularly without the balsamics. May the 
good Lord forgive them. How any one who has ever no- 
ticed the remarkable, repeated and certain effect of a good 
oil of sandalwood in diminishing the dysuria, the pain and 
burning, and the discharge in an acute gonorrhea, can 
deliberately deprive himself of the adjuvant effect of this 
and similar agents, is beyond my comprehension. 

The average human mind is narrow and loves to follow 
methods and systems : one must necessarily be an internist, 
the other a localist. Why not call into action the aid of all 
possible remedies and methods of treatment? So con- 
vinced am I of the value of internal treatment in acute 
gonorrhea that if I were limited in the treatment of this 
disease to either internal or local treatment I would choose 
the former. (It is just the opposite in subacute and 
chronic gonorrhea: there the local treatment is much more 
important than the internal; but this will be discussed in 
a future chapter.) 

The first internal prescription I give has generally the 
following composition : 

1$ Potassii citratis, 3 ij 
Potassii bromidi, 3 ij 
Liquor potassii hydroxidi, 3 i 
Ext. hyoscyami fl. 3 i 
Ext. tritici fl. 3 vi 
Aquae, q.s. ad, g vi 



42 GONORRHEA AND ITS COMPLICATIONS 

Sig. Tablespoonful three or four times a day in, or fol- 
lowed by, half a glass of water. 

Where the urine is excessively acid and there is strong 
ardor urinae this combination acts surely and well. It 
quickly neutralizes the acidity of the urine, the act of urina- 
tion is made much less unpleasant, and the patient's sub- 
jective symptoms are decidedly improved. It also acts to 
a certain extent as a preventive of chordee. This prescrip- 
tion lasts three or four days, depending upon whether the 
patient takes it four or three times a day, and is as a rule 
not repeated. 

Where the urine is not very acid I leave out the liquor 
potassii hydrox. and often I leave out the fluid extract of 
hyoscyamus and give instead tablets or granules of hyos- 
cyamine 1-100 gr. three or four times a day, or atropine 
sulphate 1-150 gr. twice or three times a day. 

I believe that this prescription, given at the beginning 
of the acute stage of the disease, has a definitely beneficial 
effect in limiting the inflammation. When the patient is 
through with this prescription I begin the administration 
of what we call the balsamics. The balsamics most com- 
monly in use are oil of sandalwood, copaiba and cubebs, 
which latter may be administered in the form of the pow- 
dered cubebs or the fluid extract of cubebs or the oil of 
cubebs or, which is the best preparation, oleoresin of cubebs. 
Personally, however, I have completely discarded copaiba 
and cubebs in my private practice (we still have to pre- 
scribe copaiba to dispensary patients) and have limited 
myself exclusively to oil of sandalwood and its combina- 
tions or derivatives. 



TREATMENT OF ACUTE GONORRHEA 43 

I prescribe them only in capsule form; it seems to me 
an unnecessary cruelty to the patient to give him sandal- 
wood either on sugar or in water or in the emulsion form. 
I generally prescribe two 5 minim capsules three to four 
times a day, the patient thus taking thirty or forty minims a 
day. I either give no sandalwood at all or if I give it, I 
give it in what I consider efficient doses. To youthful or 
very delicate persons five minims four times a day is often 
sufficient. 

Many patients have no trouble whatever in taking oil 
of sandalwood, and these patients need no other internal 
treatment. Many patients, however, cannot take it for two 
reasons: either it upsets their stomach, causing belching, 
anorexia, or it causes pain across the kidneys. Some- 
times the pain may be quite acute. To such patients we 
must give some of the various combinations and derivatives 
of oil of sandalwood. I frequently prescribe gonosan, 
santyl, iactosantal, thyresol, and arrheol. The dose of all 
of them varies from one to two capsules three to four times 
a day. Thyresol may also be given in tablet form. 
Arrheol may be given in doses of from eight to twelve cap- 
sules a day. Where pain in the urethral canal and at the 
neck of the bladder is a prominent symptom gonosan acts 
best, because it possesses, besides its antiblenorrhagic ef- 
fects due to the santal oil, distinctly anodyne effects due 
to the kava-kava. 

That is all the medicine the patient takes for his gonor- 
rhea as such. This is continued throughout the course of 
the disease, with the difference that after the third week, 
when the discharge has greatly diminished, only two or 
three five minim capsules are taken pro die. 



44 GONORRHEA AND ITS COMPLICATIONS 

Special symptoms, such as chordee, balanitis, etc., re- 
quire special treatment, which is considered under the ap- 
propriate heading. 

I do not give hexamethylenamine as a routine drug in 
gonorrhea. I could not convince myself that it had any 
beneficial effect. Sometimes it aggravates the condition by 
making the urination more painful. Where there is a 
mixed infection, however, there it is given invariably, but 
then we must see to it that the urine is not alkaline, for 
hexamethylenamine (urotropin) acts but feebly or not at 
all in an alkaline medium. In such cases 1 usually pre- 
scribe it in conjunction with sodium benzoate, which acidi- 
fies the urine or with the recently introduced sodium acid 
phosphate, NaH 2 P0 4 , whose action is still more certain in 
this respect. This salt is not the official sodium phosphate, 
which is chemically the disodic hydrogen phosphate, 
Na 2 HP0 4 , and which is used as a cholagogue and laxative. 
The salt I am referring to is given in doses of ten to 30 
grains three times a day. It may be given in the form of 
tablets containing both hexamethylenamine and the mono- 
sodic acid phosphate — five grains of the former and ten to 
fifteen grains of the latter. 

Hexamethylenaminae, gr. v 
Sodii benzoatis, gr. x 
Mf . pulv. No. i 
Tales doses, No. xij 
S. One powder in a glass of water three to four times 
a day. 

Hexamethylenaminae, gr. vij ss 
Sodii (mono) acidi phosphatis, gr. xv 



TREATMENT OF ACUTE GONORRHEA 45 

M.f. tabella, No. i 
Tales doses No. xxx 
S. One in a glass of water three to four times a day. 

Methylene blue is a peculiar drug, and though it has 
been used for many years in the treatment of gonorrhea it 
is still impossible to define its status. In some cases it 
seems to act nicely, in a large number not at all. Occa- 
sionally when the patient becomes intolerant of santal oil 
preparations it is necessary to make a change, and then I 
prescribe it. It should never be prescribed alone, but al- 
ways with some extract of belladonna and a small amount 
of cinnamon ; nutmeg is not advisable in the acute stages : 

Methylthioninae hydrochlor., gr. ij 
Phenyl salicylatis, gr. iij 
Extr. belladonnae, gr. 1-6 
Pulv. cinnamomi, gr. ss 
M.f. capsula No. i 
Tales doses No. xxx 
S. One capsule three to four times a day. 

LOCAL TREATMENT 

The injection treatment of gonorrhea is still a mooted 
question. It is a genuine bete noire. Many physicians 
even nowadays are afraid of it. There is no effect without 
a cause, and there is a cause for the suspicious and timid 
attitude of the profession towards the injection treatment. 
The fear, which is in many instances a wholesome fear, is 
due to the fact that injections, if given in the superacute 
stage of gonorrhea, or if administered bunglingly and 
forcibly, or if too strong in themselves or in too strong 



46 GONORRHEA AND ITS COMPLICATIONS 

a concentration, are apt to do a great deal of damage. Very- 
many strictures were undoubtedly caused by the too pow- 
erful injections used by our forefathers. Even at this 
late day we not rarely see cases in which an injection 
administered by the patient himself, or even occasionally 
by the physician, has caused an almost immediate exten- 
sion of the inflammation to the posterior urethra, or severe 
strangury with retention of urine, or hemorrhage, or 
epididymitis, or prostatitis. And when one deals with 
patients of a low degree of intelligence who cannot be 
taught not only how to be aseptic but even how to be 
ordinarily clean, it is best to leave out injections altogether ; 
and the physician who has not or does not want to take the 
requisite time and the required gentleness for the trifling 
but important process of washing out and injecting the 
urethra should also leave injections alone. It will not be 
the best kind of treatment, but no injections are better 
than carelessly or imperfectly administered injections. So, 
as said, there is a real reason for the fear of injections. 

But, as we have said many times before, the improper 
use or abuse of a measure does not militate against its 
proper use. And the conscientious and careful practitioner 
need have no hesitation in resorting to the treatment of 
gonorrhea by injections. I begin to use them with the 
patient's very first visit. The only class of cases I do not 
use them in is in the superacute cases, but this is really 
not necessary to mention, because it will be mentioned later 
on, and it is the cases of moderate severity that I am dis- 
cussing here — this should all the time be borne in mind. 

The drugs used for injection are certainly very numer- 
ous, as is readily seen by referring to the section on drugs, 






TREATMENT OF ACUTE GONORRHEA 47 

While it is good to have a large number to select from, for 
very frequently a case which will not yield to one drug 
will yield to another, still in the majority of cases we limit 
ourselves to a small number of drugs, and it is to these 
only that we will refer in this chapter. 

The injections may be divided into three classes: cleans- 
ing, antigonococcal and astringent. 

While these injections may be used interchangeably dur- 
ing one and the same period, still, as a rule, each class is 
indicated for a different stage of the disease. When a 
patient comes in a superacute condition, with the discharge, 
so to say, bursting forth, and the penis red, swollen and 
painful, then I use only the cleansing injections. But this 
stage under proper management never lasts longer than 
two or three days, and then the time comes for the anti- 
gonococcal or gonocide or antiseptic injections. Many 
patients never have that very acute stage; that is, even a 
first or acute gonorrhea may start in and proceed with only 
moderate symptoms. In such cases the cleansing injec- 
tions are left out and the gonocide injections are com- 
menced forthwith. The astringent injections are reserved 
for the last or declining stage, when there is but a drop or 
so of discharge and gonococci are either entirely absent 
or very scant. 

The most eligible cleansing solutions are a one per cent, 
solution of borax or sodium bicarbonate or l-10th per cent, 
solution of sodium chloride. Boric acid is not very good 
for the purpose, for mild as it is, it is still nevertheless 
irritating, occasionally. 

It is best to prescribe those solutions double the strength 
that it is intended the patient should use and direct him 



48 GONORRHEA AND ITS COMPLICATIONS 

to dilute them half and half with boiling water. For it is 
important the patient should use the solution hot. If he 
can use it of a temperature of 45° C. (113° F.) he will 
kill two birds at one shot, because the above temperature 
is fatal to the gonococcus. But in the superacute stage of 
which we are speaking now, some patients are very sensi- 
tive to heat and cannot stand a higher temperature than 90 
or 100° F. A higher temperature is not only painful but 
occasionally increases the inflammation. 

We must always remember the purpose of these injec- 
tions: they are merely cleansing and, unlike injections of 
class two and three, they are not to be held in the urethra. 
They are injected and allowed to run right out. Of course, 
as with all injections, the patient must be instructed always 
to urinate before using the injection. If he cannot urinate 
at a given time, then he is to delay the injection until he 
can. 

I. FORMULAS OF CLEANSING INJECTIONS: 

1. Sodii bicarbonatis, gr. cl 
Aquae destill. steriliz., Oj 

Mix with equal volume of hot water and inject two or 
three syringefuls every hour or two. (If you cannot do it 
so often, do it as often as you can.) 

2. Sodii boratis, gr. cl. 
Aquae destill. steriliz., Oj 

Directions same as with injection No. 1. 

3. Sodii chloridi c. p., gr. xxx 
Aquae destill. steriliz., Oij 

Directions same as with No. 1. 



TREATMENT OF ACUTE GONORRHEA 49 

Some use a normal salt solution (0.7 to 0.9 per cent.). 
I don't consider it necessary to use the solution so strong. 

We now come to the formulas for the gonocide solutions. 
There is but little limit to the frequency of the injections. 
If one would use the injections regularly every hour or 
two, his urethritis would certainly be cured in a very short 
time. These injections are to be held in as long as pos- 
sible — fifteen minutes (if the patient has the patience and 
perseverance), ten minutes, or at least five minutes. If the 
patient (after urinating, of course) takes the injection in 
the recumbent or semi-recumbent position, he will have 
less difficulty in retaining the solution as long as may be 
necessary. 

The antiseptics that have been recommended as gonocides 
are many. The principal ones are mercuric chloride (cor- 
rosive sublimate), potassium permanganate, hydrogen 
peroxide, thalline sulphate, ichthyol and silver salts. Mer- 
curic chloride is mentioned here only to be condemned in 
the most emphatic terms. It is a drug that works mis- 
chief with the urethral canal. The urethral mucosa is an 
exceedingly delicate membrane and must be dealt with 
gently. We must kill the gonococci, but we must not de- 
stroy the mucous membrane. I am satisfied that many 
cases of stricture, urethral erosion and other complications 
can be laid at the door of corrosive sublimate. Potassium 
permanganate is not one of my prime favorites. If used 
in strength to be efficient it is too irritating. Not that we 
cannot cure a gonorrhea with it alone, but there are better 
drugs, and in medicine the best is none too good. Still in 
some cases it seems to be superior to any drug in or out of 
the pharmacopeia. 



50 GONORRHEA AND ITS COMPLICATIONS 

Hydrogen peroxide is of little value as a gonocide. 
When I do use it, it is in very dilute solution as a cleansing 
agent, merely preliminary to the gonocide injection. Thai- 
line sulphate is a well tried gonocide and I use it fre- 
quently. Ichthyol I use in obstinate cases of a gleety char- 
acter. But the gonocide drugs par excellence are the silver 
compounds. 

The best known of silver compounds is silver nitrate. I 
use it very extensively in chronic urethritis, but to use it 
in acute gonorrhea would be folly. It not only increases 
the pain and the discomfort (often producing retention, 
strangury, blood in the urine, etc.) but actually aggravates 
the disease. For the silver nitrate increases the discharge, 
and the more abundant the discharge the better the gono- 
cocci like it; this is their pabulum and they multiply in it 
much more rapidly than in a urethra with but a scanty 
discharge. For this reason my endeavor from the first 
minute I get the patient is to reduce the amount of dis- 
charge in the urethra to a minimum; not by the aid of 
drying astringents, but by mechanical means ; by frequently 
flushing the urethra with the syringe and by making the 
patient take lots of liquid, so that he is obliged to urinate 
very often and thus wash his .urethra from within. And 
so nitrate of silver in acute gonorrheal urethritis is out of 
the question. Silver iodide, recently recommended, is of 
little or no value. Silver fluoride is irritating. 

In short, the inorganic preparations of silver are not well 
suited for the treatment of acute gonorrhea. We must 
have recourse to the organic compounds. Here we are 
confronted with an embarras des richesses. We have pro- 
targol, argyrol, argonin, argentamine, argentose, argentol, 



TREATMENT OF ACUTE GONORRHEA 51 

nargol, largin, picratol, silberol, ichtrargan, albargin, etc., 
etc. While I have given every one of them a pretty thor- 
ough trial, I shall not go into a consideration of the ad- 
vantages and disadvantages of every one of them. I will 
simply state that practically I have limited myself to the 
first mentioned, namely protargol and argyrol. And while 
argentamine, argonin and albargin are used abroad con- 
siderably, in this country the above two compounds are 
the only ones in general use. 

Argyrol is an excellent silver compound and is the least 
irritating of all silver compounds. And in very irritable 
or sensitive urethras that is the silver compound of choice. 
Protargol, however, seems to be more penetrating and on 
the whole is more effective. An excellent way is to use, as 
I have been doing for some time, the two salts alternately. 
That is, I will prescribe one bottle of protargol solution 
and one of argyrol and tell the patient to use the protargol 
one day and argyrol the next day, or to change with each 
injection. Under these injections the secretion diminishes, 
the inflammation subsides and the gonococci disappear 
rapidly. 

II. FORMULAS FOR GONOCIDE SOLUTIONS 

4. Protargol, 0.5 

Aquae destill., 200.0 

M. Ft. solutio lege artis. Detur in vitro nigro. 

Sig. Use one syringeful at a time (two to four drams, 

depending on the capacity of the man's anterior urethra, 

which I always measure) and hold in five to ten minutes. 

You must be sure that the solution of protargol is prop- 



52 GONORRHEA AND ITS COMPLICATIONS 

erly prepared. Improperly prepared it contains lumps 
and will prove irritating. The best way to make a solu- 
tion of protargol is to pour the water into a wide graduate 
or a mortar, and then throw, with a sifting motion, the 
protargol on the water; it is light and floats. Leave it 
without shaking or stirring; in a few minutes it will be 
found to have become dissolved. As seen, I commence 
with a y^ per cent, solution (1:400). The amount may be 
raised to one or two per cent., but I seldom go beyond one 
per cent. 

5. Argyrol, 10.0—20.0—50.0 
Aquae destill., 200.0 

Use the same way as the protargol solution. 

6. Thalline sulph., 1.0 
Aquae destill., 200.0 

This is a one-half per cent, solution ; the strength may be 
raised to two per cent., but one per cent, is generally the 
most satisfactory. 

7. Ichthyol, 4.0 to 6.0 
Aquae destill., 200.0 

This, as stated previously, is used only in "dragging" 
cases and is good as an alternate injection. 

When the discharge has become thin, serous and scanty, 
when the gonococci are practically absent, then it is, as a 
rule, advisable to finish up with an astringent injection. 
For this purpose we may use one of the following injec- 
tions. 



TEEATMENT OF ACUTE GONORRHEA 53 



III. FORMULAS FOR ASTRINGENT INJECTIONS 

8. Zinci sulphatis, gr. viij 
Aquae destill., § iv 

Inject three or four times a day. 

9. Zinci sulphatis, gr. viij 
Plumbi acetatis, gr. viij 
Aquae destill., § iv 

Shake well. Inject three or four times a day. 

10. Zinci sulphocarbolatis, gr. xvj 
Aquae destill., § iv 

11. Zinci sulphatis 

Plumbi acetatis, aa gr. viij 
Tr. opii, 3 j 
Tr. catechu, 3 ij 
Aquae ad, § iv 

The following, however, is my favorite : 

12. Zinci sulphatis, gr. viij 

Bismuthi subcarbon (vel subnitr.), 3 iij 
Bismuthi subgall., 3 j 
Hydrastis aquos, § j 
Pulv. acaciae, 3 jss 
Aquae ad § iv 
M. f. mistura lege artis. 
Keep bottle flat and shake well before using. 

This leaves a protecting coating over the urethral canal, 
exerting a soothing and healing influence. The coating 



54 GONORRHEA AND ITS COMPLICATIONS 

remains in the urethra until the next urination. This in- 
jection finishes up the treatment. 

[If prepared by a competent pharmacist this prescrip- 
tion makes a smooth homogeneous mixture, like an emul- 
sion. Prepared by an incompetent pharmacist, it is lumpy, 
gritty, and often proves irritating to the urethra.] 



CHAPTER VII 
CASE REPORTS 

Before going further, I will present two typical cases of 
acute gonorrhea — first attacks — the method of actual treat- 
ment pursued, and the difference in the results obtained, 
on account of a slight misstep on the part of one patient. 

A. A., age 26, made a night of it on December 1st. He 
had a big dinner, drank a good deal of wine, and had in- 
tercourse four or five times. In short he did comply with 
all the requirements which Ricord gave as necessary in 
order to be certain to get a gonorrhea. The woman ap- 
parently supplied the gonococcus. On December 4th he 
felt a tickling in the meatus, towards evening of the same 
day he felt considerable burning in the urethral canal, and 
the meatus became puffy. On the morning of the 5th he 
woke up early with a painful erection and some discharge. 
Urination was scalding and painful. During the day the 
discharge gradually increased and urination became more 
and more painful. He was sure that the woman, a re- 
spectable young widow, was clean and healthy, and there- 
fore he could not have anything serious. He thought it 
was all due to a strain. He bathed his penis in hot water, 
which relieved him temporarily. The following day things 
kept on going from bad to worse, and on December 7th he 
came to consult me. He had never had any venereal 

trouble, in fact prior to that night he had had no inter- 

55 



56 GONORRHEA AND ITS COMPLICATIONS 

course for six months — having been away to Mexico and 
having a wholesome fear of the tropical women; and this 
was his first attack. 

Status prcesens. The meatus puffy, the glans swollen, 
the entire penis very hot, the prepuce swollen and edemat- 
ous, though retractable, and a large amount of greenish 
pus pouring out of the meatus. A little tenderness in the 
right groin, showing beginning involvement of the inguinal 
glands. I tell him to urinate, and the urine comes out 
slowly and in a very thin stream, showing great congestion 
of the urethral canal. Urination exceedingly painful, and 
he grits his teeth during the process. The last few drops 
of urine look as if they were tinged with blood. He passed 
altogether about six ounces of urine, in three separate 
glasses, and each portion is a little turbid, though the last 
only slightly so. The urine is very dark in color and very 
acid. Though no microscopic examination was necessary 
— the diagnosis was perfectly plain without it — still one 
was made, and it showed the presence of numerous extra- 
and intracellular gonococci. 

To think of attempting to abort a case like this would 
have been absurd. Nor did I think it advisable to use any 
injections at that stage. Antiseptic or "gonocide" injec- 
tions would have proved irritating, and all that could be 
accomplished by cleansing injections could as well be ac- 
complished by washings from within — by the frequent pass- 
ing of a bland, diluted urine. 

I gave him the following mixture: 

5 Potassii citratis, 5 ij 
Sodii bromidi, 3 iij 



CASE REPORTS 57 

Liq. potassae, 3 i 
Ext. hyoscyami. fl., 3 i 
Aquae menthae pip. q.s.ad § vj 
Sig. § ss in water four times a day. 

Besides this I gave him arbutin pills, one gr. each, one to 
be swallowed every hour, followed by half a glass of water. 
I also told him to dip the penis in hot water every two 
hours for about five minutes at a time, and to wrap the 
organ in gauze saturated with aluminium acetate solution. 
For the threatening swelling in the groin I gave him the 
following ointment: 

IJ Ung. hydrargyri, 3 ij 
Guaiacol, 3 ss 
Adipis, 3 vi 
M. ft. unguentum 
Sig. Apply three times a day covering with gauze. 

The improvement was immediate as far as the ardor 
urinae was concerned. The erections were also consid- 
erably improved, but in the night he was awakened by a 
very painful chordee. When he came next morning the 
swelling of the prepuce was all gone, and the meatus was 
less puffy and glazed. The discharge was abundant, the 
urine was light in color. I made no change in the treat- 
ment — told him to keep on doing the same thing until the 
following morning. I gave him a suppository containing 
1-3 grain of morphine sulphate and 1-120 grain of atropine 
sulphate, to be inserted at night in case there were during 
the day any indications of painful erections. He did get 
a painful erection towards evening and he inserted the sup- 



58 GONORRHEA AND ITS COMPLICATIONS 

pository and he slept through the night in perfect comfort. 
"When he came the following morning his condition had 
undergone still further improvement. The amount of pus 
was less, and so was the burning and the pain on urina- 
tion. I then gave him an anterior injection of a % per 
cent, solution of protargol, and prescribed eight ounces of 
a 14 P er cent, solution of the same silver compound, to be 
used regularly every three hours throughout the day and 
twice or once during the night, the injection to be retained 
three to five minutes each time. I also prescribed five 
minim capsules of oil of sandalwood, to be taken four 
times a day. He came every day to the office, and every 
day I used either a protargol ( % per cent. ) or a potassium 
permanganate (1-2000) injection, but at home he used the 
protargol solution exclusively. He complained once or 
twice of burning and irritation caused by the injection, 
but as the discharge and the gonococci kept on diminishing 
in amount, and the other symptoms kept on improving, I 
did not consider it necessary to make any change. On the 
eleventh day of treatment the discharge was reduced to a 
very small drop in the morning, and the gonococci were 
scanty. He continued the injections for four days more, 
without any change in the morning drop. I then gave him 
an injection of zinc sulphate and bismuth subnitrate (see 
Formulas and Prescriptions), which he used three times 
a day. After three days of this injection the drop disap- 
peared. I told him to discontinue all treatment for three 
days and come for examination. He came early in the 
morning, with the night's urine in the bladder. I exam- 
ined him and pronounced him cured. For there was not a 
trace of discharge, the meatus was perfectly normal, and 



CASE REPORTS 59 

the urine was free from any traces of shreds. I expressed 
his prostate, and the secretion was free from any gonococci. 
He came around every third day for examination. I told 
him to resume his normal course of living. He drank some 
wine, and three weeks after I pronounced him cured he 
had intercourse, but no symptoms made their appearance 
and the urine remained perfectly clear. 

Here we have a severe case of acute first gonorrhea cured 
in eighteen days. The patient was anxious and could af- 
ford to be treated properly. He could devote and did 
devote all the time that was necessary. Not all patients 
can do that. Through neglect, insufficient or improper 
treatment the inflammation extends into the posterior 
urethra or the prostate, and then it becomes a matter of 
weeks or months instead of days. In this case, it will be 
noticed, the inflammation at no time passed beyond the 
anterior urethra. 

Case A. B. was very similar to A. A. in its history, initial 
symptoms and course of the disease. Though he could not 
attend to himself so carefully, he was getting along nicely ; 
but on the ninth day of treatment he had to walk about a 
good deal on business, and in the evening he "had" to go 
to theater with some prospective buyers; he also had to 
treat them to supper, and "had" to drink with them dif- 
ferent cocktails and wine. On the next day all his symp- 
toms were aggravated, and the second portion of the urine 
contained pus and shreds; in short he developed an acute 
posterior urethritis. I began to use instillations of 0.5 per 
cent, solution of protargol daily, but the protargol proved ir- 
ritating. I diminished the strength to 0.25 per cent., and it 
still proved irritating. I then changed to ten per cent, ar- 



60 GONORRHEA AND ITS COMPLICATIONS 

gyrol, using two e.c. at each instillation. After ten days 
very little progress was made and I changed to albargin. 
Then I changed back to protargol. It took fifty-six days of 
treatment before I could pronounce the patient cured. An 
unwise step on the part of the patient, a step forced by 
economic conditions, cost him several weeks of extra suffer- 
ing. 






CHAPTER VIII 
COMMON BACTERIAL URETHRITIS 

While common bacterial urethritis is not as frequent nor 
as important as is gonococcal urethritis, still it is frequent 
and important enough to deserve special consideration and 
be borne in mind by the physician. The physician who 
will consider every case of urethral discharge as gonorrhea 
will be correct in his guess eight or nine times out of ten; 
but in the other ten or twenty per cent, he will blunder, 
cause the patient undue anxiety, prolong the course of the 
disease unnecessarily, throw unjust suspicions in many 
cases; in other words, be untrue to his function as phy- 
sician. One of the first things for a physician to do when 
a patient with a urethral discharge applies for treatment is 
to determine the character of the discharge : is it gonococcal 
or not? Only after this point has been settled, may the 
physician proceed with treatment. 

In the vast majority of cases the differential diagnosis 
is not difficult. While exceptions do occur, still as a rule 
simple bacterial infections of the urethra are milder in 
their entire course ; the urinary symptoms are almost en- 
tirely absent : there is no scalding or burning on urination, 
no strangury, no increased frequency. The discharge may 
be quite abundant, but it is not yellow or greenish, but 
almost a pure white ; the glans is not swollen, the lips are 
not everted and puffy, nor eroded. The microscopic ex- 

61 



62 GONORRHEA AND ITS COMPLICATIONS 

animation usually settles the diagnosis: we find in the 
field numerous bacteria of various sorts, bacilli, cocci, pneu- 
mococci, bacillus coli, streptococci, but no gonococci. 

The causes of common bacterial urethritis are many. 
One of the commonest is intercourse with a woman who is 
the subject of a bad leucorrhea. And some intact virgins 
may have the worse kinds of leucorrhea ; worse than other 
women, for the latter have recourse to douches, which are 
avoided by the former for fear of rupturing the hymen. 
Relations during or immediately after the menstrual period 
is another cause. A temporary alteration in the reaction 
or chemical constitution of the vaginal secretion is an un- 
doubted cause. I have had a case of a man under treat- 
ment who would always get a urethritis when he would 
have relations with his wife when she was tired from 
shopping and traveling, or worried or annoyed. At no 
other time would he get any trouble; the wife was abso- 
lutely free from any leucorrhea or any other vaginal or 
uterine discharge. Relations with a woman suffering with 
an abscess, erosion of the cervix, or carcinoma may give 
rise to an obstinate urethritis. Another cause of bacterial 
urethritis is auto-infection. In men with long prepuces, 
where smegma is allowed to accumulate, and a balanitis or 
a phimosis results, the bacteria sometimes wander into the 
urethra and set up an inflammation with discharge. An- 
other cause, a cause which fortunately is becoming less and 
less frequent as the medical profession and the laity are 
learning the theory and practice of asepsis and antisepsis, 
is infection carried into the urethra with a sound or bougie. 

It is important to bear in mind that a bacterial urethritis 
is often implanted upon a urethral mucous membrane that 



COMMON BACTERIAL URETHRITIS 63 

had been once the host of the gonococci, bnt is now entirely 
free from them. That a man with a gonorrhea may get an 
additional infection we know ; but it is necessary to bear in 
mind that the urethra that was once the subject of a gonor- 
rheal inflammation forever remains a locus resist entiae 
minor is and is more vulnerable to infection than an intact 
urethra. Let us assume that A has had gonorrhea for two 
or three years. By persistent and scientific treatment he 
is cured in the real sense of the word. Urethroscopically 
the mucous membrane is normal, the severest tests fail to 
bring out any gonococci, though they may bring out a non- 
bacterial, aseptic discharge. The man is given permission 
to marry. The young intact wife has some leucorrhea — 
she has never used any vaginal douche — there is excessive 
indulgence and the result is that the husband develops a 
urethral discharge. He is frightened to death; he thinks 
his gonorrhea was not properly cured, that he has a relapse 
and that he has infected his wife. But a careful examina- 
tion shows a few common bacteria and no gonococci. Three 
or four injections stop the discharge, the wife is ordered a 
vaginal douche, and no further complaints are heard from 
those quarters. It is well to bear in mind that we may 
have an unadulterated gonorrheal infection, a mixed infec- 
tion (gonococci plus other bacteria) and a common bac- 
terial infection implanted upon a previously gonorrheal or 
healthy urethra. 

The prognosis in simple bacterial urethritis is good ; and 
its course is usually short, though if not treated or wrongly 
treated it may become chronic and extremely obstinate. If 
neglected it may also give rise to epididymitis, prostatitis 
and vesiculitis, and these complications may even be more 



64 GONORRHEA AND ITS COMPLICATIONS 

resistant to treatment than when occurring as complications 
of gonorrhea. 

The treatment is simple and consists in the use of injec- 
tions of mild antiseptics; potassium permanganate, 1-3000, 
silver nitrate 1-5000, mercuric chloride 1-15,000, mercuric 
oxycyanide 1-5000, chinosol 1-1000. Sometimes the dis- 
charge disappears completely — and all the other slight 
symptoms with it — after three or four injections, and it is 
such cases that establish some physician's reputation as a 
great specialist, and give rise to the popular idea that 
gonorrhea can be cured in three days. 

In addition to the injections, a mild alkaline diuretic 
may be administered. 



CHAPTER IX 

CHANCROIDAL URETHRITIS 

This term is applied to an inflammation and discharge 
caused by chancroids within the urethra. The correct term 
is of course urethral chancroids, but I deliberately use the 
term chancroidal urethritis to impress it upon the phy- 
sician's mind that a discharge from the urethra may be 
something else than a gonorrhea. While mistaking a sim- 
ple bacterial urethritis for gonorrhea may not have any 
dire results, overlooking a chancroid or chancre within the 
urethra may have disastrous results for both patient and 
physician. The physician should always palpate the 
urethra; that alone will sometimes give a hint of the true 
condition of affairs. Then the pain, whether spontaneous, 
on pressure, or on urinating, is generally localized in the 
anterior urethra ; the discharge, whether profuse or scanty, 
is generally mixed with blood. And on microscopic exam- 
ination no gonococci are found. The Ducrey bacillus is 
not easily identified in the pus from urethral chancroids. 
Buboes are apt to complicate both gonorrhea and chan- 
croid, and as both gonorrheal and chancroidal buboes are 
inflammatory in character and painful, this complication 
is of little value as a diagnostic sign ; except when we punc- 
ture the bubo and the pus shows the presence of the bacillus 
of Ducrey. I am strongly opposed to going into an acutely 

inflamed urethra with a urethroscope, but in exceptional 

65 



66 GONORRHEA AND ITS COMPLICATIONS 

cases, where it is necessary as an aid to diagnosis, it is 
permissible, especially as chancroids are usually situated 
within the first inch of the urethra. 

The treatment of urethral chancroids consists in irrigat- 
ing the anterior urethra with normal saline solution, with 
1 to 10,000 bichloride, or with 1 to 1000 chinosol solution. 
After three or four days of this treatment, instillation of 
iodoform oil (1 part of iodoform in 20 parts of sterilized 
olive oil) 10 to 20 drops three times a day, or the insertion 
of thin and oblong (suppositoria urethralia) iodoform sup- 
positories should be resorted to : 

Iodoformi, gr. ij 
01. theobromae, gr. xij 
M. f. Suppos. No. 1. Tal. dos. No. xij 
Sig. One t. i. d. 

Chancroids within the urethra are sometimes very resist- 
ant to treatment, as we cannot use any very radical meas- 
ures; we cannot cauterize them, as we can external chan- 
croids. 

After the chancroids have healed it is sometimes neces- 
sary to proceed with prolonged and systematic dilatation 
of the urethra, so as to prevent the formation of a stric- 
ture, or to stretch it if one has formed. 



CHAPTER X 
SYPHILITIC OR CHANCRE URETHRITIS 

That a chancre can be situated within the meatus or fur- 
ther in the urethra, giving rise to discharge, etc., is well 
known, but nevertheless this is frequently overlooked by 
the physician, who, as we said before, is too apt to regard 
every kind of urethritis as gonorrheal. If the possibility 
of a chancre within the urethra is only borne in mind, the 
diagnosis is not difficult. The important points are the 
following. On palpation a slight induration or an indu- 
rated mass is felt in the meatus or further back in the 
urethra. The size of the stream is diminished, sometimes 
extremely so, the lumen may be almost obliterated ; but the 
pain is slight. The discharge is usually scanty, and on 
microscopic examination shows the absence of gonococci but 
the presence of many blood cells. Inguinal adenitis, if 
present, is indolent, painless, non-inflammatory. Of course 
the appearance of secondaries or a positive Wassermann 
settles the diagnosis, but their corroborative testimony is 
needed only in very exceptional cases. As a rule we can 
make the diagnosis without them. 

The treatment of chancre urethritis or urethral chancre 
is that of syphilis in general. The location of the initial 
lesion is of little significance. The use of salvarsan, and 
of mercury intramuscularly, by inunction or by mouth will 

result in the disappearance of the chancre. But the heal- 

67 



68 GONORRHEA AND ITS COMPLICATIONS 

ing process may be expedited by introducing into the 
urethra suppositories containing small doses of mercury, 
the most advantageous being mercurial ointment: 

Unguenti hydrargyri, gr. i (0.06) 
01. theobromae, gr. x (0.6) 
M. f. Suppos. urethr. No. 1. Tal. dos. xxx 
Sig. One bis vel ter in die. 

Instead of using cacao butter alone as a base, the phar- 
macist may be instructed to add two or three grains of 
yellow wax to each suppository, so that the prescription 
would read: 

Unguenti hydrargyri, gr. 1 (0.06) 

Cerae fiavae, gr. ij (0.12) 

01. theobromae, gr. x (0.6) 

M. f . Suppos. urethr. No. 1. Tal. Dos. xxx 

As the object of this book, as of all my other books, is 
distinctly utilitarian, my purpose being not only to teach 
but to impress the teachings upon the physician's memory, 
I will report here a case of urethral chancre which was 
mistaken and treated for gonorrhea, and which will per- 
haps be of service in preventing similar mistakes in the 
future. 

X. X., thirty-five years old, druggist by profession, 
single, has been leading a rather loose life, indulging ex- 
cessively and promiscuously. Had his first gonorrhea at 
the age of seventeen, and since then has had more relapses 
or fresh attacks than he can remember — probably fifteen 
or twenty. However, he has ceased to pay much attention 
to them, as he had learned to ' ' cure ' ' his gonorrhea quickly, 



SYPHILITIC OR CHANCRE URETHRITIS 69 

without any physician's aid. At the first appearance of a 
discharge he would take some santal oil capsules, use an in- 
jection of potassium permanganate, "finish up" with zinc 
sulphate — and in two or three weeks he would be well. 
Only in the more obstinate attacks he would consult one or 
another of the physician friends who were in the habit of 
visiting his drug store. 

On January 13 he began to notice some difficulty in 
urination ; he felt as if the stream had to pass some obstacle. 
Two or three days later there was also some burning on 
urination, which sensation gradually increased. A rather 
profuse discharge also made its appearance. He at once 
began to use potassium permanganate injections, and though 
the injection was very painful he persisted. There was 
no diminution in the discharge ; large doses of oil of santal, 
however, diminished the ardor urinae, and made the act 
of micturition tolerable. He also tried copaiba and cubebs. 
In about two weeks he consulted one of his general practi- 
tioner friends, who looked at his urethra and advised him 
an argyrol injection. The result was nil, and he con- 
sulted another physician. For six weeks he kept on using 
different antiblenorrhagics and injections for his gonorrhea, 
but the condition was not only not improving, it was get- 
ing worse. His urinary stream was getting smaller and 
smaller. He consulted another physician, who attempted 
to pass a sound, which attempt caused severe pain and 
hemorrhage, declared he had a stricture and dismissed him. 
The patient then consulted me. I listened to his history, 
looked at his body, felt his urethra, his axillary, inguinal 
and cubital glands, and told him that it was not gonorrhea 
that he needed treatment for, but syphilis. He might or 



70 GONOKRHEA AND ITS COMPLICATIONS 

might not also be suffering from a gonorrheal urethritis, 
but about his being the victim of syphilis in an active stage, 
perhaps in a virulent form, there could be no question. 
The rash on the body was unmistakable. I called his at- 
tention to it, and asked him if this did not make him or 
his physicians suspicious. No, he always suffered from 
pimples (acne) ; he did speak about it to one of the doc- 
tors, but the doctor said that the eruption was probably 
due to the copaiba, cubebs and santal oil that he was taking. 

He naturally objected to the diagnosis of syphilis, and 
truculently asked if it was not possible that I was mis- 
taken. I told him that I was not in the habit of declaring 
emphatically that a patient was suffering with syphilis un- 
less the diagnosis was absolutely certain; if there was one 
chance in a hundred of a mistake, I would say: probably 
syphilis. But in his case there was no room for doubt. 
Further examination disclosed extensive condylomata lata 
and acuminata (which the patient had taken for piles), 
and numberless mucous patches in the mouth, in the 
pharynx and on the tonsils. He was aware, he said, that 
his throat was sore, but as he had frequently suffered, in 
the winter particularly, from sore throat, he paid no atten- 
tion to it. The patient was an excessive smoker, and not- 
knowing the nature of his trouble he went on smoking in 
spite of his mucous patches. The axillary glands were 
considerably enlarged, but the inguinal glands were only 
slightly swollen. The lack of inguinal adenopathy is a 
phenomenon which we observe not infrequently in chancre 
situated within the urethra. 

I told the patient that he was a danger to everybody he 



SYPHILITIC OR CHANCRE URETHRITIS 71 

came in contact with, to every customer, to his relatives, 
to the community at large, and that he must at once sub- 
ject himself to vigorous and persistent treatment ; his uvula 
was ulcerated and was in danger of dropping off unless 
vigorous treatment was instituted immediately. Even 
after these emphatic declarations the patient was not quite 
convinced. The mind refuses as long as possible to be- 
lieve things which are painful. He asked me if I would 
not take a Wassermann test, just to make sure. I said 
emphatically, no. To make a Wassermann would mean 
that I was not absolutely certain of my diagnosis, and this 
was not the case in his instance. He went to another phy- 
sician who had a Wassermann made, and onlv when the 
result came as positive (-j — | — | — |-) did he come for treat- 
ment. And he was a very meek patient then. His uvula 
had in the meantime ulcerated through on one side, and as it 
interfered with his speech and swallowing I clipped it off. 
I started at once active treatment. Gave him a full 
dose of salvarsan, followed by injections of mercury every 
other day. There seemed to be indications of softening of 
the hard palate, and as I feared ulceration I gave the mer- 
cury (salicylate, oxy cyanide and salicyl-arsinate ; I believe 
that in desperate cases we get better results by frequently 
changing the salt of mercury) in maximum doses. The 
throat and mouth were sprayed with a 1-5000 mercuric 
chloride solution, and, besides, antiseptic formaldehyde- 
generating tablets were ordered to be slowly dissolved 
every hour. For the condylomata a powder of equal parts 
of resorcinol and calomel was prescribed (a remarkably 
efficient application to all venereal warts) ; 



72 GONORRHEA AND ITS COMPLICATIONS 

^ Resorcinol, 

Hydrarg. chlor. mitis, aa 3 ij 
M. f . pulvis subtilis 
Sig. Apply externally. 

For the urethra I ordered bougies of unguentum hydrar- 
gyri (0.05) and oleum theobromatis (0.8) : 

IJ Unguenti Hydrargyri U. S. P., 0.05 
01. Theobromatis, 0.8 
M. ft. suppos. urethrale No. I 
Tales doses No. XII 
Sig. Insert one t. i. d. 

The effect of the treatment was immediate. I have often 
said, if the results of treatment were as prompt, as posi- 
tive, as clearly apparent in other diseases as they are in 
syphilis we would have no therapeutic nihilists, the anti- 
drug quacks would not be deluding the ignorant and non- 
critical public with their false and sophistical statements, 
and doctors would not form the subject of satire in humor- 
ous, and would-be humorous magazines. 

The patient is of course still under treatment, but his 
Wassermann taken every month shows -f-, — > ° r ~\ • 

I repeat the fact that a chancre may occur within the 
urethra should be strongly impressed on the physician's 
mind. It would save him humiliating and dangerous 
errors, it would save the patient valuable time. One month 
saved in the beginning means the saving of a year after- 
wards. 

Tubercular and Neoplastic Urethritis need merely be 



SYPHILITIC OR CHANCRE URETHRITIS 73 

mentioned. They are very rare, but it is well that the phy- 
sician should know of their existence, for they are some- 
times the expression of a lesion higher up in the genito- 
urinary tract. 



CHAPTER XI 
CHEMICAL URETHRITIS 

The cases of chemical urethritis are numerous and well 
authenticated. And with the growing tendency to self- 
medication, to injecting strong chemicals for the pur- 
pose of curing and preventing gonorrhea, they are becoming 
more and more frequent. I have reported four unmistak- 
able cases of chemical urethritis — three in the Medical Rec- 
ord and one in The Critic and Guide. As I consider chem- 
ical urethritis of great importance, too often overlooked or 
neglected by the physician, I will devote a little more space 
to it than to the other varieties of non-gonorrheal urethritis. 
The cases reported by me were as follows : 

Case I. Mr. X. ? 28 years old, was to be married on Sep- 
tember 21, 1910. Just a week before, September 14, he 
considered it necessary to cohabit with a prostitute. Men 
of a certain class seem to regard it a sacred obligation to 
bid adieu to their bachelorhood in this dastardly manner. 
The temptation is very great to break out in a tirade against 
the brutes, who, a few days, sometimes even a few hours, 
before going to the marriage bed, will subject themselves 
and their future wives and children to the risk of infec- 
tion, because, forsooth, after marriage they intend to be 
faithful to their wives and therefore want to have a "last 
fling. " But what 's the use ? The brutes don't read medi- 
cal literature, and if they do they are not affected by our 

74 



CHEMICAL URETHRITIS 75 

tirades. And so Mr. X. had intercourse on the 14th. On 
the 16th he noticed, or thought he noticed, a tickling in the 
urethra. After a few hours the tickling disappeared. On 
the 17th he thought it returned. In view of the close ap- 
proach of the important day he became thoroughly fright- 
ened — though I believe there was nothing the matter with 
him, the tickling being more in his mind than in his ure- 
thra — and consulted — a reputable specialist? No; a drug- 
gist. This druggist seems to have been particularly ig- 
norant. His advice to the patient was to dissolve one 
antiseptic tablet (containing 7.7 grains of corrosive subli- 
mate!) in about half a glass of water and syringe three 
times a day, using several injections for each seance. 

The patient did as told and syringed out his urethra four 
or five times with a half-ounce syringe. This was before 
going to bed. He suffered agonies the whole night, and 
the pain at any attempt at urination was so severe that he 
abstained. The following morning he applied to me. The 
penis was four or five times its normal size. The swelling 
and edema were enormous. The gl ans was so puffed that 
it was difficult to find the meatus. The patient was badly 
frightened, but constitutionally he was not ill, no fever, 
no malaise, no stomatitis, no bad odor, in short, no 
symptoms of mercurial poisoning. He showed me the 
tablets which the druggist had given him; they were, as 
stated, 7.7-grain corrosive sublimate tablets, combined with 
an equal amount of ammonium chloride. He indicated to 
me the amount of water in which he dissolved the tablet 
and the amount was between four and six ounces. In other 
words, the strength of the bichloride solution which he 
used as a urethral injection was about 1 in 250 to 1 in 350. 



76 GONORRHEA AND ITS COMPLICATIONS 

And in all he used about three grains of corrosive subli- 
mate; but, of course, he let the injection run right out. 
That there were no systemic symptoms I ascribe to the fact 
that the strength of the solution by necrosing the mucous 
membrane prevented the absorption of the poison; the 
effects therefore were purely local. That his bladder was 
apparently not injured, I ascribe to the fact that he in- 
jected gently and did not force open the shut-off muscle. 
He tried to urinate unaided, but failed. I then with 
great difficulty anesthetized the urethra, passed a small 
catheter, and withdrew twenty-two ounces of urine. The 
patient at once felt relieved. For the penis I ordered 
compresses of liquor alumini acetatis (Burrow's solution) ; 
to do away with the strangury I ordered rectal supposi- 
tories of morphine sulphate (gr. %) and atropine sulphate 
(gr. 1-60) ; also, internally a mixture of potassium bro- 
mide, potassium acetate, arbutin, and fluid extract of 
triticum; also to drink frequently of a cold infusion of 
linseed. This treatment improved the patient's condition 
at once. The swelling went down considerably; the pain 
and burning on urination disappeared almost entirely. 
But on the next day a profuse thin discharge made its ap- 
pearance and the urine contained numerous flocculi. The 
patient was, of course, sure he had gonorrhea, but I was 
convinced of the contrary. Numerous examinations failed 
to disclose a single gonococcus or a gonococcus-like dip- 
lococcus. It was pure — one might say chemically pure — 
pus, caused by an irritating antiseptic. I used no local 
treatment whatever — only internal demulcents and mild 
diuretics, and the discharge gradually diminished; it is 
now reduced to the fraction of a drop in the morning, 



CHEMICAL URETHRITIS 77 

simulating the morning drop of gonorrhea, and the urine 
contains flocculi ; they are, however, entirely different from 
Tripperfaden and they, as well as the minute discharge, 
are entirely free from cocci. The wedding, which was 
necessarily delayed for a month, is to take place in a few 
days and I have no hesitancy in giving him my unquali- 
fied permission.* During one period in the treatment 
there seemed to be a tendency to the formation of stricture, 
but several dilatations with Kollmann's dilator, followed 
by the instillation of a 1 per cent, solution of thymol iodide 
in oil, restored the urethra to its normal caliber, and it is 
now perfectly normal in this respect. 

Case II. This case concerns a young man who was suf- 
fering with too frequent nightly emissions and who was 
advised to use an injection of zinc sulphate as a remedy. 
The prescription called for zinc sulphate, 2 drams; water, 
1 pint. After using this injection for two weeks he no- 
ticed a slight thin discharge; he thought this was semen 
(!), and increased the frequency of the injections. The 
discharge then increased, becoming thicker, according to 
his statement. He then went to a physician, and in spite 
of telling him the history of the case, in spite of assuring 
him that he had never had intercourse in his life, the doc- 
tor proceeded to treat the case as one of gonorrhea. (We 
are sometimes too ready to consider our patients liars.) 
He never examined the discharge, but gave him the regu- 
lation treatment of copaiba and santal oil internally and 

* The patient was married on November 1 ; on the 18th he reported 
himself as perfectly well, and an examination failed to disclose any 
pathological condition, except that the urine still contained a few 
small sterile flocculi. 



78 GONORRHEA AND ITS COMPLICATIONS 



potassium permanganate as an injection; later on he 
changed the potassium permanganate to an organic silver 
preparation. Under this treatment the case was getting 
gradually worse, the discharge was increasing and so were 
the nightly pollutions, and what is worse, the patient devel- 
oped a stricture. When he applied to me for treatment 
the discharge was thin, but profuse, and no gonococci what- 
ever, after numerous and repeated examinations could be 
found. About 2% inches from the meatus there was a 
stricture, which permitted the passage with some difficulty 
of 18 F. I told him to discontinue all treatment for ten 
days and present himself at the end of that period. He 
did. His discharge had diminished materially, being only 
a few drops in the morning and practically nothing during 
the day. I then began to dilate his stricture, which 
yielded completely to twelve dilatations. The only other 
local treatment I gave him was the instillation of a dram 
of a 1 per cent, solution of thymol iodide in olive oil. The 
stream of urine became normal, the discharge disappeared, 
with the exception of a minute drop in the morning, which 
also finally yielded to small anterior injections of 5 per cent. 
alcohol (alcohol U. S. P. 1 part, distilled water 19 parts). 
I have not seen the use of alcohol as a remedy against ure- 
thral discharges mentioned anywhere, but it has rendered 
me good service in some very obstinate cases. In some in- 
stances I use it 10 to 20 per cent, strong and even stronger. 
Case III. The third case was one of what I call silver- 
nitrate urethritis, of which thousands and thousands of 
cases walk the land, and I report it, not because of its 
rarity, but because of its commonness, in order to call at- 
tention as forcibly as I can to a form of malpractice very 



CHEMICAL URETHRITIS 79 

prevalent in our profession; well-intentioned malpractice, 
but malpractice, nevertheless. I refer to the custom, 
handed down to us from former decades, of "testing" the 
reality and permanence of a gonorrheal cure by injecting 
into the urethra a strong solution of silver nitrate. And 
if there is anything I am convinced of in the handling of 
genitourinary cases it is that many a cured case of gonor- 
rhea may become, by repeated injections of silver nitrate, 
converted into a rebellious or practically incurable case of 
chemical or bacterial urethritis. In the early days of my 
practice I was guilty of the same practice and more than 
once have I injected a, to all intents and purposes, cured 
case of gonorrhea — no discharge, no gonococci, no shreds 
— only to have the patient come back with an obstinate dis- 
charge, which it took weeks and often months to cure ; and 
after each "testing" the discharge was less and less amen- 
able to treatment. And I state it as my positive opinion that 
thousands of people are walking the earth with urethral 
discharges which were caused by assaulting the urethra, 
weakened by gonorrheal infection, with an irritant chemi- 
cal, and who would have remained perfectly well if their 
urethra had not been subjected to any such heroic tests. 
The late Lassar was the only one of the "big" men whom 
I heard condemning the silver nitrate test in most un- 
equivocal language. I trust that these lines may have the 
effect of inducing some colleagues to discard the test alto- 
gether, or, at least, to be very cautious and mild in its 
application. 

This case is a clear-cut case of silver nitrate urethritis. 
Mr. 0., 22 years old, noticed a urethral discharge on May 
22, 1908. It was the first time he ever had any trouble. 



80 GONORRHEA AND ITS COMPLICATIONS 

He came to me for treatment May 23. Examinatioi 
showed the presence of numerous gonococci. Under th< 
treatment the discharge completely disappeared in three 
weeks. I kept him under observation for three wee! 
more and then discharged him cured. I use the word 
cured, because contrary to the opinion of some urologists, 
I believe that gonorrhea can be as perfectly and as radi- 
cally cured as many other diseases, say chancroids, or 
eczema, or scabies. There was absolutely no discharge ; the 
urine was clear of shreds, the expressed secretions from 
the prostate and the sediment from the centrifugalized 
urine showed no gonococci, and I told him that I consid- 
ered him perfectly cured. I felt especially justified in 
doing this, because at no time were there any symptoms 
of posterior involvement and I felt sure that the infection 
was all the time limited to the anterior portion. To the 
question whether he could marry safely, I replied in the 
affirmative. "But," I said, "if you want to feel at per* 
feet ease, come a month or so before you intend to 
married and I will give you again a thorough examina- 
tion." And this was the last I saw or heard of him nntil 
October, 1909. He became engaged in the spring of that 
year and the wedding was to take place in September. 
Early in August he called at my office to be examined, but 
was told that I was away in Europe and would not return 
until the beginning of October. He then went to another 
physician, to whom he told the entire history of the case. 
And he also told him that I considered him perfectly cured 
and he considered so himself, because during the thirteen 
or fourteen months his urine had been perfectly clear and 
he had no symptoms of any kind. 



CHEMICAL URETHRITIS 81 

The doctor proceeded to apply the beer-silver t- 
Though the patient was not a beer drinker and del 
beer, he was told to drinli ra] gl 
evenings in sue n. This produced absolutely do 
The doctor, however, was i I with t! but 

proceeded to inject rilver nitrate. I nev( il«l find out 
what the stn agtfa of the Bolution was, but the patient said 
that the pain was int i raJ boon later the nre- 

thra began to discharge. Thia was tab a by tl . itor 
as positive proof of gonorrhea, which he proceeded to tr- 
He treated the patient both internally and by injectio 
and he treated him very \ y. But when he cann 

me two months Later, in - dischai | 

cording to his statement, worse than ever. I lahj the 

discharge to miiiicrniis examinations, .ill of which w 
negative as far as the gonococcal I discon- 

tinued .ill treatment for a month, with th< >tion of 

advising him hot sitz-1 The discha diminish) 

by the end of that . bat v i ow work to Btop 

the discharge entirely ; il ths before ] » : 1 1 « 1 

pronounce him cured. Bxaminati in i. under- 

taken at different peril 11 proved n 

Here a man had to suff< r pain, . and 

greal expense for seven months aa a tribute to an old brutal 
test handed down to as bj ! tradition and 

eepted by us without criticism, without analysis. There 

are only tOO many such Ca» S. And I n th< 

a bacterial infection becomes implanted <>n the originally 
sterile discharge, then we ha deal with a bacteria] ure- 

thritis, which is sometimes more rebellious to treatment 
than a simple gonorrheal urethritis. 



82 GONORRHEA AND ITS COMPLICATIONS 

Case IV. The patient, a prominent member of the phar- 
maceutical profession, contracted gonorrhea six years ago. 
As he was a clever man in pharmacy, his papers being 
sought by the pharmaceutical journals and pharmaceutical 
associations, he thought he was also clever in venereology. 
He treated himself with argyrol, protargol, potassium per- 
manganate, zinc sulphate, bismuth subnitrate, Lloyd's 
hydrastis, hydrogen peroxide, etc., locally, and with 
santal oil and its various combinations internally. And 
mirabile dictu in about fourteen weeks he was cured. That 
is, he thought he was. He had no discharge, and this to 
his mind was the proof that the gonorrhea was cured ; this 
pernicious idea still lurks in the minds of the laity, and un- 
fortunately also in the minds of many country and not a 
few city physicians. Every four to six months, however, 
he would notice again a slight discharge, which he would 
ascribe to a fresh infection. But as he would "cure' 1 ' it 
each time with a few injections of zinc sulphate and potas- 
sium permanganate, he attached no importance to these 
attacks and used no precautionary measures or prophylac- 
tics. During one of those attacks he injected himself 
rather forcibly, or perhaps the syringe was not aseptic, 
and he was laid up for three weeks with a severe epid- 
idymitis. He was then treated by a competent physician, 
and when he got well of the epididymitis he continued to 
treat himself without a doctor — for about six months — until 
he was all well — according to his statement. That is, his 
urine, which always contained shreds, cleared up almost 
perfectly, showing only a few small flocculi. Repeated 
examinations by a bacteriological laboratory showed ab- 
sence of gonococci; whether the examinations in those 



CHEMICAL URETHRITIS 83 

laboratories are always conducted with the painstaking 
care and attention to all minutiae thai such examinations 
demand, 1 do not know, bu1 all the reports he brought with 
him stated: gonococei not found. 

He remained apparently well up to about eight months 
ago. Once jn a while he would feel a little moisture aboul 
the meatus, either spontaneously or after micturition or 
defecation. It is my opinion that this was nothing but a 
little secretion of mucua from the urethral glands, or per- 
haps some prostatic fluid. Eighl mouths .• i «_»-• ► he became 
engaged, and then the little moisture increased in amount, 

and was more frequently in evidence. Again it i^ my 
opinion that it was an innocent affair — a slight orethror- 
rhea or prostatorrhea is not a rare phenomenon in enga\ 
men. But lie became annoyed, thought it was his old gl< 
and decided to cure it himself. He inquired of a physician, 
what was, in his opinion, the best treatment for chronic 

gleet and the doctor told him that as far as he knew, deep 
instillations of a live to ten per cent, solution of silver 

nitrate gave the promptest and best results. Glad of the 

information, our friend Secured a \ dram Syringe and 

filled it with a ten per cent, solution of silver nitrate. The 

very clever druggist, clever in his own line, did not know 
the difference between instillations ;md injections. lie 
held in the injection for about five minutes, in spite of the 

fact that the pain was acute. There was immediate stran- 
gury, and in spite of his repeated painful efforts to urinate 
he was unable to do so. About ten hours after the injec- 
tion, the pain, strangury, desire and inability to urinate 
became excruciating and lit 1 applied to a physician, who 
cathcterized him after much effort. He was ordered mor- 



84 GONORRHEA AND ITS COMPLICATIONS 

phine and atropine suppositories, potassium citrate and 
fl. ex. hyoscyamus internally, and hot baths. This im- 
proved the condition somewhat, but the following morning 
he woke up with an abundant purulent and sanious dis- 
charge, and the urine contained much debris and large 
shreds. Micturition was painful and frequent. He con- 
sulted three physicians in rapid succession, but expecting 
too rapid results, he was too impatient to use the prescribed 
treatment faithfully and systematically. After six or 
seven weeks of desultory treatment he applied to me. I 
found no gonococci, the discharge was practically sterile, 
but I found several strictures of large caliber. I explained 
to him his condition. I told him that he was suffering 
from chemical, in his case, silver nitrate urethritis, and I 
impressed upon his mind that if he expected a rapid cure 
he should seek another physician, that I was not a cure- 
quick doctor. Many patients need a talking to right at 
the start. It clears the atmosphere, and teaches them not 
to be impatient and not to expect miracles. My patient 
became very docile, admitting that the proverb that he 
who treats himself has a fool for a patient was even truer 
than the one used about lawyers, and he followed instruc- 
tions religiously. The treatment consisted principally in 
passing sounds and Kollmann's dilators and in instilla- 
tions and injections of sterilized solutions of aristol or 
europhen in olive oil. After four months' treatment 
twice a week at first, and once a week toward the end, I 
was able to discharge him cured. 

I wish to emphasize the following points : 

1. Urethritis of chemical origin is more common than is 
generally supposed. 



CHEMICAL DBETHEITIS 85 

2. While most cases are caused from self-administered 
injections prescribed by barbers, friends, and others, some 

eg owe their origin to tin- o\ Jou-ness of physicians. 

3. The unscientific and unjustifiable tesi of injecting 
strong solutions of silver oitrate, which should be forever 
discarded, has been responsible ?<>r vcn- many cases of 
chemical urethritis, 

4. The diagnosis of chemical urethritis is made by the 
history of the the freedom of discharge from <_ r ono- 
cocci and, generally, its improvement on being lei aloa 

Ti:l \T.MI 

Tin- treatmenl of chemical urethritis hns ln-cn outlined 
fully in the r<-port> of the cases* I merely wish to em- 
phasize that one of the most useful agents in the treatmenl 
is warm sterilized olive or almond oil, or a ' \ to 1 per cent 

solution of some orjranie iodine derivative iodoform, 

dithymoliodide, enrophen) in one of the above oil 
Tendency to stricture should be prevented by dilators <>r 

by sounds dipped in the JUSl referred to solution-. 



CHAPTER XII 

PROPHYLACTIC URETHRITIS 

Apparently there is no good without some attending evil. 
Almost every reform, every sanitary measure, is accom- 
panied with some undesirable, often unexpected and un- 
looked for results. The writer, as the readers of his works 
undoubtedly know, has been one of the earliest, strongest 
and most persistent advocates of individual venereal pro- 
phylaxis. Venereal disease, whether gonorrhea or syphilis, 
is such a terrible calamity that every measure that will 
reduce the danger of infection is to be supported vigor- 
ously, to be advocated energetically. And the fact that 
venereal prophylactics are beginning to be used quite com- 
monly is to be considered as a sign of progress, as a dis- 
tinct gain in our fight with the venereal scourge. But I 
always feared, nay I felt certain, that its initial use would 
be followed by some undesirable features. There was un- 
deniable danger that some men, feeling over-secure, would 
rush into places from which they would keep away other- 
wise; others, with contempt bred of familiarity, seeing 
that they indulged for years without any mishap, would 
become careless and would apply the prophylactic in a 
neglectful and perfunctory manner — and then there would 
be trouble and they would swear at the prophylactic and its 
advocates. Others, overconscientious and overscrupulous, 
would use too much of the prophylactic or would use an 

86 



PROPHYLACTIC URETHRITIS 87 

extra strong one, and then there would be trouble again, 
though of a differenl character. And it i> to this last 
trouble that I am referring in this chapter, because during 

the past year I have met with several eases of urethritis 

and penile irritation which, Bomewhai puzzling at first, 

were later shown to have been due to the improper li- 
the prophylactic or to the use of an improper prophylactic. 
I have therefore applied to this form of urethral and penile 
inflammation the term of prophylactic urethritis, and p 
phylactic balanitis or balano-posthitis, respectively, 
the ease m;iy be. In reality, however, it is merely a variety 

of chemical urethrit 



CHAPTER XIII 

TRAUMATIC URETHRITIS 

Traumatic urethritis results from injuries to the mucous 
membrane of the urethra produced by foreign bodies in- 
troduced into the canal. The foreign bodies are usually 
introduced for purposes of masturbation, and among the 
commonest are lead pencils, slate pencils, penholders, 
matches, sticks of wood, smooth or deliberately roughened, 
etc., etc. Of course the urethritis is rarely due to the 
trauma alone, but to the trauma plus infection: the in- 
jured and abraded mucous membrane is a favorable soil 
for the development of various micro-organisms. (The 
urethritis following the frequent or permanent use of a 
catheter is generally more due to infection than to trau- 
matism.) The diagnosis of the case is of course easily 
made by the history. But in such cases patients are apt 
to lie, on account of shame, and then the character of the 
discharge and an endoscopic examination will be of aid. 
The treatment consists in mild antiseptic injections or 
irrigations (boric acid 1 per cent., saline solution 7 to 1,000, 
potassium permanganate 1 to 3,000, chinosol 1 to 1,000, 
solution of europhen in oil, 5 per cent., etc.) and in the 
administration of oil of sandalwood and hexamethylene. 
But after the discharge and all other signs of inflamma- 
tion have subsided we should carefully examine the ure- 
thra for any strictures. For traumatic urethritis is very 
apt to give rise to strictures, and if any are found they 

should be dilated by sounds or Kallmann's dilators. 

88 



CHAPTER XIV 

TOXIC URETHRITIS 

An inflammation of the urethra may result from the 
intake of poisonous or irritating substances, or even from 
certain foods against which the particular individual has 
an idiosyncrasy. One of the worst or rather most painful 
cases of urethritis that I have ever had to treat — it was in 
the early days of my practice — was in a policeman who 
took at one dose a teaspoonful of cantharides togi ther with 
an ounce of tincture of capsicum and an ounce of tincture 
of zingiber. The mixture was recommended to him as an 
infallible aphrodisiac, and as he wanted to make a good 
showing he took it all. He soon however got such a severe 
burning, strangury and priapism that he was unable to 
have any relations at all, and in the morning he had a 
sero-sanguinolent discharge and urination was extremely 
painful. The condition was, however, relieved in a few 
hours, and in three or four days he was well. That some 
people get a urethral discharge after drinking three or 
four glasses of beer is well known, but this lakes place 
only in urethras that have been afflicted with gonorrhea. 
It does not mean in all cases that the gonorrhea is not yet 
cured. The gonorrhea may be "absolutely" cured, that is 
we may not under any circumstances be able to get any 
gonococci, and the complement fixation test may be nega- 
tive; but the urethral mucous membrane has a low resist- 

89 



90 GONORRHEA AND ITS COMPLICATIONS 

ing power and the irritation produced by the beer is suf- 
ficient to call out a discharge. Potassium nitrate (niter) 
in very large doses, one-half to one ounce, may cause a 
slight discharge in a previously damaged urethra. I had 
such a case in a man who had had several attacks of gonor- 
rhea. But the drugs above enumerated are about the only 
ones which may in very large doses cause a urethritis in 
susceptible or previously damaged urethras. The state- 
ment that a urethritis may follow the ingestion of cres 
asparagus, strawberries, etc., must be taken with a grain 
of salt. Of course everything is possible, but I would have 
to be very sure of my patients before I would accept such 
an etiology. 

The treatment of toxic urethritis is obvious: bland 
drinks and diuretics: linseed tea, sodium citrate, tincture 
of hyoscyamus, small doses of oil of sandalwood. Sup- 
positories of opium and belladonna or morphine and atro- 
pine may be necessary. No injections need be used. The 
diet should be light and bland (no spices), no coffee or 
tea or carbonated water, but plenty of milk and plain 
water. 

Diathesic Urethritis. The older writers believed that a 
urethritis may occur as a result of rheumatism, gout or 
diabetes. I do not deny this possibility, but I believe that 
a modern careful examination would show such cases to 
be of simpler origin : a microbic origin would be revealed. 
A profuse urethral discharge may also occur in the course 
of pneumonia or typhoid; but here also, I believe, we have 
to deal with the exacerbation or awakening of a dormant, 
semi-cured gonorrhea. 



CHAPTEB xv 

URETHRITIS FROM EXCESS AND 
MASTURBATION 

We are told thai urethritis may occur from exoesai 

sexual intercourse, from excessive ui; ed libido and 

from excessive masturbation. That this may OCCUr in a 
urethra which lias been weakened by a previous e-nnorrhea 

— even if the. gonorrhea lx' entirely cured — I admit, lint 

that if may take place in an intact urethra, I deny. It is 

not wise to be dogmatic about anything in medicine, and 

I would therefore ehange the phrase "I deny" to "I 

Btrongly doubt.' 1 I have DOW under treatment a mastur- 

bator, who has been masturbating for twenty y< he 

will not. masturbate for months at a time, bul when he once 
yields, he will masturbate l () , IS and 20 times a daw In 

the last, few acts just a few drops of a thin fluid will come 

out — not at. all Like semen — and he will i»e completely ex- 
hausted. Bu1 he has never developed any trace of dis- 
charge, though his urine contains a few small shreds from 
the posterior urethra, as that of most masturhators do- 

I have had persons under treatment who made perfecl 
beasts of themselves in intercourse (no, this is unjust to 
the beasts, as they never overdo it). Some men have been 
in the habit of performing the act so many times during 
one night, that in the last acts only a sangninolent fluid 
would issue. And still they did not develop any urethritis. 

91 



92 GONORRHEA AND ITS COMPLICATIONS 

I therefore must deny the probability if not possibility of 
urethritis from excess per se. 

Ricord relates the case of a physician who had had no 
intercourse for six weeks and then passed the entire day 
from 10 in the morning to 7 at night with a woman whom 
he loved. lie desired to have relations with her, he was in 
a state of continuous excitement, hut lie was unable to 
overcome her resistance. His excitement was there! 
not allayed, and three days later he developed a painful 
urethritis. We do not know however the previous history 
of that doctor's urethra, and Ricord 's case is ti not 

conclusive. That long, angratifled excitement will induce 

a congestion of the posterior urethra is well known, hut 
between congestion and inflammation there is quite a gap. 



CHAPTEB xvi 

THE WIDELY VARYING CONDITIONS 
KNOWN AS CHRONIC GONORRHEA 

Before we pi ODtlilM 

gonorrhea m iVw preliminary remarks an y essential. A 

t coiiLrlotn.nit inn n] 

prised under the term chronic rrhea. While wl 
Acute ( fonorrh A.cu1 I 

refer to a distinct and definil the 

n chronic Thee or chronic gonorrheal urethritis. 

In fa<t so confused and indefii "_ r y. pathology 

and symptomatology ofchroni gonorr h ea tin not 

:t it aa a separate entity, and can sp it simply as 

chronic urethriti 

And it will be seen that while I * 1 the vai 
of acute urethritis and it> hi I i so in 

tin- case of the chronic tonus of urethritis, but treat them 
all together under one head; because, whether a chronic 
urethril is be due to the ^ 

18 generally a mixed infection) Oi nondia.t.ri.i! 

the treatment ia practically the same. 

To show how widely varying in every i le- 

ments etiology, pathology, symptomatology and prognosis 

n- the conditions which go under tin- nam.- chronic 
gonorrhea, we will briefly present s: 

Case i. Man has had ponorrhea for eighteen months, 

Baa been treated in the ap] 1 fashion alo i ithouf 



94 GONORRHEA AND ITS COMPLICATIONS 

interruption since the first day the discharge showed itself. 
The urine is clear; there are no shreds ; only in the mornint: 
the meatus is glued together. By strong expression a very 
minute amount of moisture, hardly enough to be called 
secretion, is expressed. A smear from tins secretion is 
perfectly sterile. Still the man is worried and is developing 
neurasthenic symptoms on account of the persistency of 
that little moisture. I suspect that the trouble is due to 
over-treatment, suspend all treatment, tell him to live his 
normal, regular life and partake moderately of beer and 
wine as he used to. In a week the meatus becomes normal 
and there is no further moisture or secretion, and after a 
thorough test the case is pronounced eared. 

Case 2. Similar to Case 1, except t hat there ii a good- 
sized "morning drop." In the daytime no secretion of 
any kind, the meatus perfectly dry. No gonococcL I B 
pect that the morning drop is kept up by the silver nit rale 
irrigations and instillations which he has been receiving 
two or three times a week. I stop those and order a 3 per 
cent, zinc sulphate solution injected twice a day, after thi 
days to be injected only once a day. In about a week the 
discharge disappears and the patient is quite well. 

Case 3. Had gonorrhea for about eight months. Xo 
symptoms now except a little minute amount of discharge in 
the morning and throughout the day. Numerous smears 
show the absence of gonococci. The urine is slightly turbid. 
A urethroscope examination shows a practically normal 
mucous membrane, no localized patches, no inflammation of 
Littre's glands or of the crypts of Morgagni. Prostate nor- 
mal. It is a typical case of post-gonorrheal aseptic catarrh. 
I order general tonic measures, hot and cold sitz baths on 



CHRONIC GONORRHEA 

alternate days, and Leaving the urethra entirely alo 

After two weeks the condition ally improved. A 

injections of zinc acetate and hydi 

plete. 
Case 4. Had the (torsi attack of gonorrhea thn 
», of which he claims bo have been entirely c nd 

attach a 5 ear ;iL r <>. and has had it even 

ilighl m amoonl but is always thei n half an hour 

after urinating the discharge will appear iponl 

can he readily expressed. In the two-glass 

the urine trery Qumerous in both glasses. Has been oi 
b hand injection all the time, frith Dim rnal rem- 

edies. The gonocoed in the dischar e in great multi- 
tudes. An examination with a bo 
pre of three organic strictures, irritable and painfol. 

It is clearly seen that the injection he has used 1 

ond the lirst stricture and was pra<-t iealh Ear 

aa any effect on the entin it of the mucous membn 

beyond thai stricture was concerned. Endoscopic axamina- 
tion shows numerous sclerosed patches and a r.-iy 

inflamed posterior urethra, Alter irrigating the urethra so 

that the tin id passes nut clear and without any shreds and 
pressing the prostate, a prostatitis with BjOnOCOCCJ in the pi 
tatic discharp' is plainly demonstrated There arc also in- 
dications that the Seminal Vesicles are affected. This 1 

course is in an entirely different category from the previous 
three cases, and demands dilatation of the strictures, irrigs 

tions of the entire urethra, instillations in the posterior ure- 
thra, endoscopic applications to the sclerosed and granular 
patches, and prolonged prostatic massage l>efore a cure IS 
effected. 



96 GONORRHEA AND ITS COMPLICATIONS 

Case 5. Has had the disease for two years, but not con- 
tinuously. Some times for two or three months he will 
have no symptoms whatever. The urine will be perfectly 
clear, transparent, and free from shreds. Then all at once 
a discharge will appear, which will keep up for a month 
or two and then, with or without treatment, will disappear. 
An examination shows the urethra to be practically nor- 
mal. The Urine in both glasses is clear, but if he urinates 
in a third glass and at the very last is told to strain hard, 
then the last portion will contain some small shreds and a 
little secretion, which examination shows to come from the 
prostate. Expression of the prostate yields large masses 
of muco-purulent material. In short, the examination 
shows that the man really has no urethritis, only a prosta- 
titis, and that the reinfections and irritations of the urethra 
come from the prostate gland. Treatment directed exclu- 
sively to the prostate effects a cure in four months. 

An analysis of the above cases, brief and cursory though 
it be, shows that what goes under the name of chronic gonor- 
rhea is not a distinct entity, and that we cannot hope to treat 
all cases of chronic gonorrhea by one set formula. Here, 
if anywhere, we must "treat the patient and not the dis- 



ease. ' ' 



But now, having emphasized these things, having, I hope, 
succeeded in impressing upon the mind of the physician 
that discrimination and judgment is necessary in the treat- 
ment of every case of chronic gonorrhea (much more so 
than in the acute variety), I permit myself to give a general 
outline of the treatment of the majority of cases as they 
present themselves to the general practitioner. 



CHAPTER XVTT 
THE TREATMENT OF CHRONIC GONORRHEA 

Here, as in acute gonorrhea! ire may divide the treatment 

into general, internal and local. 

General. The genera] treatment in chronic gonorrhea fa 

of minor importance. Things that may prove v.ry in- 
jurious in acute gonorrhea axe permissible in the chronic 

variety; not. only permissible hut sometimes distinctly in- 
dicated. The patienl may Lead his usual node of life, and 
need observe but little restriction even a.s far as alcohol ii 

concerned. In fact, patients who have been need to alco- 
holic beverages often do better when permitted to partake 
of small amounts of wine or beer than when entirely cut 
off from any alcoholic indulgence. Many cases who hav, 
obstinate catarrh of the urethra which does not seem to 
yield to any measures show rapid improvement when per- 
mitted to drink some beer or wine or even whiskey, i g 
the chapteri Gonorrhea vs. Alcohol. Tobacco and Sexual 
Intercourse.) Exercise is also permissible, in fact many 
patients begin tO do y^vy much better when permitted to 
exercise. Of course, common senee is lure necessary as in 
every other department of medicine. For instance, if the 
patient has as a part of Ins chronic gonorrhea also a chronic 
prostatitis, particularly one which shows ready exacerba- 
tions, then he will abstain from any exercise which involves 

the low T er part of the body, such as running, bicycling, auto- 
it: 



98 GONORRHEA AND ITS COMPLICATIONS 

mobiling, etc. This is also true of cases which had an epi- 
didymitis. In some patients an epididymitis is apt to re- 
occur on the slightest provocation, and such patients will 
do better to abstain from any exercise, such as walking, etc., 
until practically cured. Sexual intercourse in moderation 
is also permissible ; nay, in many cases it is the strictly en- 
joined complete abstinence which is responsible for the 
keeping up of the prostatitis, congestion of the posterior 
urethra and discharge. The only injunction you need give 
to the patient is to see to it that his bowels move regularly 
and that he does not permit himself to get constipated, but 
this is a good injunction for anybody, even one who does 
not suffer with gonorrhea. Bathing, both hot and cold, is 
decidedly useful. A change of air is not indicated. When 
a physician sends a ease of chronic gonorrhea to the country 
or for a sea voyage it is been use he has exhausted all his 
resources, he wants to get rid of the patient or he wants 
to try something on a "perhaps." I have not found it 
necessary in any case. 

Internal Treatment. The internal treatment is also of 
very minor importance in chronic gonorrhea. Indeed in a 
very large number of cases of chronic gonorrhea we can get 
along without a single drop of any internal medication 
whatever. If we do give internal treatment it is not with 
the hope of attacking the gonorrheal foci but for secondary 
reasons. For instance, if there is a mixed infection or an 
accompanying cystitis we may give urotropin and sodium 
benzoate. When we use sounds or dilators in the urethra 
we also give liberal doses of urotropin both before and after 
treatment to prevent infection. In giving silver nitrate in- 
stillations the reaction is sometimes very severe — that is, 



TBEATMENT OF CHRONIC GONORRHEA 

the strangury and burning on urination. To all 
symptoms we give sandalwood or gonosan, Where the 

patient shows a tendency to recurrent epididymitis, then 
good doses of sodium salicylate, salol or aspirin mi in- 

dicated. Sometimes when the patient OOlish and in- 

clined to be neurasthenic we must give him a placebo. 
placebo will have no direct effect on the »-unn- 

tract, but it is good 1'or bis nem To t, I do not 

exclude internal nmdieation entirely in the treatment of 
chronic gonorrhea, but I do not give it with ai > of 

direct effect on the genito-nrins dons. 

Local Treatment. This is the i tant and is in 

the vast majority of i only treatment indi 

Briefly staled, the treatment eonai and irri- 

gations, instillations, dilatation and i 

tions. 

The drug par excellenoe in chronic oreth] i r 

nitrate, and with this drug alone, properly used, we can 
cure a very large percentage of our ■ It is na d eitl 

in the form <>t' irrigation, injection, instillation or concen- 
trated application. For irrigation purposes I use it in the 
strength of 1 in 10,000, increasing t! i 1 in 

l,ooo. By increasing the strength very gradually 
irritation, with the consequent discharge, strangury, and bo 
forth. The amount used per irrigation dii 
ounces (250 to 1,000 c.c). This irrigation is repeated twice 

a week as a rule. In many eases once a week suffic The 

entire urethra is irrigated, for while in the acute disi 

we distinguish between anterior and posterior urethri 
there is practically no line of demarcation in the chronic 
variety — the entire canal is more or less affected. It' the 



100 GONORRHEA AND ITS COMPLICATIONS 

neck of the bladder also shows signs of implication in the 
gonorrheal process the bladder is also irrigated, but here it 
is best to use a few drops of a strong solution, 1 per cent., 
by instillation. 

Irrigation may be performed by the means of the well 
known Janet- Valentine irrigator, but I prefer to use a 
large Janet-Frank syringe of 150 to 250 c.c. capacity. 

For injection purposes I use the silver nitrate in the 
strength of 1-1,000 to 1-250, and generally from 2 to 6 
drams at a time. While the irrigating fluid is permitted to 
run right out the injection fluid is made to remain in the 
urethra from 2 to 5 minutes. 




Guyon Syringe and Catheter. 



Instillations I use generally when the posterior urethra 
and the neck of the bladder is affected. For this purpose 
I use almost exclusively the soft rubber Guyon catheter and 
syringe. The strength of the solution varies from 1 to 5 
per cent, and from 3 to 20 drops are deposited on the 
affected portion. 

When endoscopic examination shows the presence of local- 



TREATMENT OF CHRONIC GONORRHEA 101 

used patches of inflammation or erosion then topical applica- 
tions through the endoscope, application to Hie spat, ere 
indicated. The application an made by the aid of a cotton 
earner, and the strength of the Mirer nitrate solution may 

be from 1 to 10 per cent. Instead of silver nitrate, a mix- 
ture of equal paitl of tincture of iodine and phenol is often 
markedly beneficial. 




(iinon Syriag^ » r,IK 'l' Bake 




"-Tl^llcJJ^aDaQu^jd 



Ultzmaii Syringe 

I stated that by silver nitrate alone we can cure a lar«_re 
majority of eases. But not all. In BOme 08868 silver ni- 
trate exerts a decidedly injurious effect The patent's 

mucous membrane seems to possess an idiosyncrasy against 

silver nitrate. The condition of the urethra remains either 
eid i rely unaffected by the silver nitrate or becomes WOTBe. 
In such cases wo must have recourse to other chemicals, 
and zinc sulphate is one of the best. How do we know 
whether to use silver nitrate or zinc sulphate? We do not. 
The treatment of chronic urethritis is unfortunately still 
in the empirical stage. We can never predict before- 



102 GONORRHEA AND ITS COMPLICATIONS 

hand just how a certain chemical will affect a patient's 
urethra and how long the treatment will last. We must 
simply keep on trying. We use first one drug and if the 
patient's urethra responds well to the treatment we con- 
tinue to use it, perhaps changing the strength now and then, 
but if after a few applications (i.e., irrigations, injections or 
instillations) the condition remains the same or becomes 
worse, then we have to change to another drug. It is per- 
fectly ridiculous, to keep on with silver nitrate for months 
and months at a time, as some physicians do even when they 
do not notice the slightest improvement. Because silver 
nitrate is a very beneficial drug in some cases of chronic 
urethritis, it does not mean that it is beneficial in all cases. 
The beneficial effect must show itself soon, and if it fails 
to show itself a change is indicated. 

The zinc sulphate may be used in strengths of J of 1 per 
cent., to 5 per cent., that is from 1 gr. to the ounce of water to 
25 grs. to the ounce of water. Often it is well to alternate 
the zinc sulphate with some other astringent, such as copper 
sulphate, 1 to 2 grs. to the ounce. Latterly iodine has given 
me good results in a restricted number of cases. It is 
generally in those cases in which silver nitrate proves irri- 
tating that tincture of iodine in a very diluted form (5 to 
25 drops of the official tincture to an ounce of water) proves 
beneficial. For applications through the endoscope the 
pure tincture may be used. 

If the patient cannot come to the doctor's office frequently 
enough then we must sometimes prescribe an injection for 
him to use on himself. In such cases the best injections are 
a 2 per cent, solution of ichthyol or a 2 per cent, solution 
of zinc sulphate or zinc acetate, or the zinc sulphate, lead 



TREATMENT OF CHRONIC GONORRHEA 103 

acetate and bismuth sub-nitrate mixture (see Formulary). 
Alternating injections will always give better results than 
using the same injection uninterruptedly. I therefore 
often have my patient use two injections on the same day 
or different injections on alternate days. 

Irrigations, injections and instillations will cure the great 
majority of cases, but where there are strictures, either fully 
formed or in the process of formation, or sclerosed patches, 
all these measures will often prove inefficient. Here we 
have another procedure which is generally very helpful. 




Dilator for Anterior Urethra 




Dilator for Posterior Urethra 



This is dilatation by the means of sounds or dilators. What 
the exact rationale is of the benefit by sounds and dilators 
is not very clear, but there is no question that dilatation, 
if not abused, has a remarkably beneficial effect on the 
course of chronic urethritis. The use of the sounds is 
simpler than that of dilators, but the superiority of the 
dilator over the sound lies in the fact that the former can 
be passed through a small meatus and then dilated in the 
urethra to any desired circumference, while in treatment 
with sounds we must perform meatotomy if the patient 



104 GONORRHEA AND ITS COMPLICATIONS 

happens to have a narrow meatus, which is quite frequently 
the case. The proper interval for the use of sounds and 
dilators is once every five days. Once a week is often suffi- 
cient, but they should never be used more than twice a week. 
I do not believe, however, that much benefit can be derived 
from leaving the sound or dilator in one or two minutes. 
Ten minutes is about the proper period. It may be left in 
as long as twenty minutes. 

Where there are indurated patches and inflamed glands 
and lacunae, it is well to massage them over the sound 
(while the sound is in the urethra), and we often succeed 
in expressing a good deal of secretion from them. Properly 
performed such a massage over sound or dilator with pains- 
taking expression contributes a good deal towards the cure 
of the most obstinate gonorrheas. 

A small percentage of patients are very sensitive to the 
use of dilators or sounds and are apt to get what we call a 
urethral chill and an aggravation of all other symptoms, but 
this usually occurs only after the first or first and second 
treatments. If done gently and aseptically, all trouble can 
be avoided. Always remember, however, to have the pa- 
tient take a good dose of hexamethylenamine before he comes 
to your office and give him one when he is leaving the 
office. 

There are on the market also irrigating dilators, where 
the irrigation and dilatation can be performed simul- 
taneously, but I believe that these instruments are best left 
in the hands of the specialist. 

The proper method of procedure in treating a patient by 
sounds or dilators is as follows: (1) the patient urinates; 
(2) the urethra is washed out with a warm boric acid solu- 



TREATMENT OF CHRONIC GONORRHEA 105 

tion, 2 per cent., or a 1-10,000 mercury oxycyanide solu- 
tion; (3) the sound or dilator, properly asepticized and 
lubricated (with a water soluble and not an oily lubricant) 
is passed into the urethra and allowed to remain ten, fif- 
teen or twenty minutes; (4) the urethra is again washed 




Irrigating Dilator for the Anterior Urethra 




Irrigating Dilator for the Posterior Urethra 

out with a warm boric acid or a normal salt solution; 
(5) the injection, irrigation or instillation proper, with 
silver nitrate, zinc sulphate, diluted tincture of iodine, or 
whatever else may be decided upon, is administered. 

Such a treatment as outlined above gives results, definite 
and positive results. And I personally believe that, prop- 
erly speaking, there is no such thing as an incurable case 
of gonorrhea. Every case is curable, for all practical pur- 
poses. There are hundreds of thousands of cases of un- 
cured, and under our present conditions incurable cases, 
but the fault is not with our lack of knowledge. It resides 
in the social and economic conditions of the patient, which 
prevent him from employing a competent physician for the 
proper length of time. 



106 GONORRHEA AND ITS COMPLICATIONS 

VACCINOTHERAPY 

The reader may be surprised that in outlining the treat- 
ment of acute and chronic gonorrhea I have not made any 
mention of the vaccines or bacterins. The reason is a very 
simple one. I have not done so because I am not an en- 
thusiastic believer in them. Now, do not draw false con- 
clusions. It does not mean that I do not believe in the 
vaccine treatment of any disease, nor does it mean that I 
do not believe in the value of vaccine treatment of certain 
complications of gonorrhea, particularly of arthritis. It 
does not even mean that I deny that the administration of 
vaccines may prove of value in some cases of chronic gonor- 
rhea. It does mean, however, that I believe the percentage 
of cases in which the gonococcic vaccines or bacterins, either 
the simple or the mixed, is of benefit, is so slight that it is 
not worth while advising their use to the general practi- 
tioner. 

I believe that on the whole more harm than good is being 
done by them. I have patients sent to me from different 
parts of the country on whom vaccinotherapy has been prac- 
ticed for weeks, months and even years, and not only with- 
out any benefit but with distinct injury, and for this reason 
I do not care to enlarge upon the subject in this book. Still, 
if a physician wishes to use the vaccines or bacterins in any 
of his obstinate cases he is welcome to do so. He needs no 
instructions from us on this subject, for the packages come 
ready prepared and he can readily obtain all the necessary 
literature from the manufacturers. 

I wish, however, to repeat that both from my personal 
experience and from an analytical study of the reports of 



TREATMENT OF CHRONIC GONORRHEA 107 

conscientious investigators (not those who rush into print 
with their successes with every new remedy), I am con- 
vinced that the antigonococcic serums, vaccines and bac- 
terins, not even excepting the latest of Nicolle and Blaizot, 
are of but slight if any value in the treatment of gonorrheal 
urethritis. That an efficient vaccine may be produced in 
the future is possible, but this is not yet the case. We have 
not yet an efficient anti-gonococcic vaccine, and of those we 
do have we are still in ignorance as to dosage, intervals of 
administration, indications and contraindications. To 
shoot a patient full of bacteria on the principle that they 
may do some good is neither scientific nor fair. I at least 
cannot give it my approval. 

And in this connection the following quotation from 
Adami is pertinent. This careful and thoughtful physician 
says : 

"Thus as a final principle it may be laid down — and I 
do this with a full sense of the necessity and responsibility 
that attaches thereto — that vaccine therapy is not to be 
undertaken by the ordinary practitioner; there are too 
many dangers attaching thereto; and with this corollary, 
that, excellent as may be the stock vaccines prepared by 
certain firms, to advertise these light-heartedly and recom- 
mend them and their employment far and wide deserves 
the condemnation of this association and all interested in 
the wellbeing of their fellow-men. ' ' (Symposium on Vac- 
cine Therapy, Meeting of the Association of American 
Physicians, 1910, quoted from American Journal of 
Urology, Jan., 1911, p. 25.) 

And the following quotation from Vaughan emphasizes 
still more strongly the necessity for caution and the great 



108 GONORRHEA AND ITS COMPLICATIONS 

danger that may arise from the use of vaccines by the gen- 
eral practitioner : 

1 ' Every time an unbroken protein is introduced into the 
body it carries with it, and as a part of it, a poison. From 
the very careless, rash and unwarranted way in which ' vac- 
cines ' of most diverse origin and composition are now used 
in the treatment of disease, this matter certainly cannot be 
understood or its danger appreciated by those who subject 
their patients to such risks. It should be clearly under- 
stood that all proteins contain a poisonous group — a sub- 
stance which in a dose of 0.5 mg. injected intravenously 
kills a guinea-pig. Not only do these proteins contain a 
poison, but when introduced parenterally the poison is set 
free, not in the stomach, from which it may be removed, but 
in the blood and tissues. It is possible that vaccine therapy 
may become of great service in the treatment of disease. 
Even now there are occasional brilliant results which are 
reported, while the failures and disasters are not so widely 
advertised." (From Vaughan's book, "Protein Split 
Products in Relation to Immunity and Disease." ) 



CHAPTER XVIII 

THE LENGTH OF TIME REQUIRED TO CURE 
CHRONIC GONORRHEAL CONDITIONS 

"How long will it take me to get cured?" is a question 
very frequently addressed to us by our patients afflicted 
with chronic gonorrhea or its complications. To some it is 
just a matter of interest, to some it is a matter of vital im- 
portance, either because they want to or must get married 
at a certain time, or because their financial resources are 
limited and they can spend only so much. But invariably 
my answer is: "I don't know; it will take as long as it 
will take." And I explain to them briefly but understand- 
ably, the character of their disorder, the difference between 
an acute and chronic gonorrhea, the anatomic structure of 
the genital organs and glands, and why it is impossible to 
state beforehand, even approximately, how long it will take 
to cure a certain case. For instance, a case of chronic 
prostatitis or seminal vesiculitis. We will say it takes on 
the average four to six months; it may take only two 
months ; but it may take a year or more. If the patient is 
willing to subject himself to treatment, under these condi- 
tions, well and good ; if not, also well and good. The intel- 
ligent and financially able patient is sure to agree. Under 
no circumstances is a patient taken under false pretenses, 
or under a misunderstanding. And it is only with such 
complete previous understanding that the treatment of a 

chronic gonorrheal patient can be carried on successfully, 

109 



110 GONORRHEA AND ITS COMPLICATIONS 

and the patient never has any pretensions. Some physi- 
cians, for fear of losing the patient, do not make it clear to 
him as to the probable length of time, or even deliberately 
mention a short period : a month or two. More is the pity. 
They hurt themselves eventually more than if they told the 
truth frankly at the outset. And they also hurt the medical 
profession in general, by destroying the confidence of the 
public in the reliability of the doctor's statements. Of 
course not every physician is sufficiently secure financially 
to be able to deal with patients with perfect independence 
and not to mind if he does lose a patient. Again, more is 
the pity. Because it is only the perfectly independent 
physician who can do his patients the most good. 

And the following case will demonstrate what can be 
accomplished in apparently hopeless cases by persistent un- 
remitting treatment. Mr. A, age 28, got an attack of gonor- 
rhea at the age of 24, and he has had the gonorrhea and 
some of its complications ever since. He was treated by 
several general practitioners. I examined him and found: 
two strictures, barely passable by 15 F ; a beautiful prosta- 
titis, with prostate enlarged and sensitive, with purulent 
secretion easily expressible; a bilateral spermatocystitis ; 
granular and sclerosed patches in the urethra. A slight 
gleety discharge constantly present: not only in the morn- 
ing, but also throughout the day. Urine turbid, full of 
shreds and bacteria, and some pus. The patient knew that 
his condition was a severe one, and he did not ask how 
long it would take him to get cured. In fact he said he 
did not care how long it took. He was disgusted with his 
condition and he was determined to get cured, if there was 
any possibility of his getting cured. He came faithfully 



TIME REQUIRED TO CURE 111 

twice a week for over a year ; the prostatitis improved after 
six months, but the spermatocystitis was rebellious and 
showed no improvement. Nor was it possible to improve 
the condition of the urine. I told him that there was but 
little hope of further improvement, unless the treatment 
was continued for a very long time. He said he did not 
care if it took five years. He came regularly once or twice 
a week for another year. He became a joke, a regular fix- 
ture in the office. No weather could keep him back. Every 
Sunday and Wednesday he was there. I got tired of him. 
I should have been glad if he had also gotten tired. But 
he did not get tired, nor discouraged. Had he been a sexual, 
neurasthenic, with imaginary troubles, with no anatomic 
basis for his sufferings, I would have gotten rid of him 
long before. But he was not a bit neurasthenic, and there 
was a real pathologic basis for his condition. And so I 
consented to continue to treat him. At the end of three 
years and two months I discharged him as absolutely cured. 
His urine was clear and sparkling, the granular patches and 
strictures were no more, and the prostate and seminal 
vesicles were normal. Not only were their secretions free 
from gonococci, they were free from any other bacteria as 
well. Here was a case of patience well rewarded. Pour 
years' irregular treatment which aggravated his condition 
before he came to me, and three years under my care — 
seven years altogether. And why was he so methodical, so 
persistent, so regular in his treatment during the past three 
years? First, because he had absolute unquestioning con- 
fidence; second, because he wanted to get well; and third, 
most important, there was a little girl whom he was going 
to make his wife. 



112 GONORRHEA AND ITS COMPLICATIONS 

And so, while I believe that every case of gonorrhea and 
its complications is curable, we must refuse to give a time 
limit. And we must also bear in mind another thing. A 
urethra that has been the subject of gonorrhea of many 
years' standing presents forever after a locus resist entiae 
minoris, and may under certain predisposing causes de- 
velop a mild urethritis, a slight catarrh. You discharge a 
patient cured. Urethra normal in every sense of the word, 
urine clear and sparkling, no complications of any kind. In 
six months the patient comes to you, with a slight discharge, 
or perhaps only a little burning sensation on urination or 
during intercourse. You examine him. No gonococci, no 
bacteria of any kind, or perhaps a staphylococcus here and 
there. You give him one or two instillations of AgN0 3 , 
and he is well again for a year or two. Then he comes 
again with the same slight trouble, and again you fix him 
up in one or two visits. I have several patients who come 
regularly once or twice a year for the purpose of passing a 
sound or receiving a silver nitrate instillation. They come 
at the first appearance of a disagreeable symptom in the 
urethral canal or in the prostate : a little itching or burning, 
or a little heavy sensation. And then they are all right 
again, and are thus kept in good condition all the time. 
I don't see anything terrible or objectionable in a patient, 
who had suffered with gonorrhea for several years, being 
obliged to make a few visits to a specialist once or twice a 
year, so as to prevent the development of any trouble in 
his weakened urethra. People go to the dentist regularly 
once or twice a year. Why should not people who went 
through a severe attack of gonorrhea visit the genito-urinary 



TIME REQUIRED TO CURE 113 

specialist once or twice a year, to prevent any possible 
trouble, or to cut short any trouble in its incipiency ? 

To summarize: I believe in the curability of every case 
of chronic gonorrhea and its complications. But as to the 
time required, there is no> telling definitely. If pressed for 
an answer I would say: A small percentage get cured in 
a month or two, a larger percentage in four to six months, 
a somewhat smaller percentage in eight to twelve months, 
and a very small percentage requires longer than a year — 
a year and a half, two years, or exceptionally, if there are 
many complications, even three years. 

In conclusion I will reproduce a little editorial note from 
the Critic and Guide (November, 1914) entitled: Curable 
and Incurable. It is a propos the subject under discus- 
sion and is as follows : 

CURABLE AND INCURABLE 

There is not a single incurable case of gonorrhea. 

There are in the United States a million incurable cases 
of gonorrhea. 

Very contradictory, at first sight. 

Not a bit contradictory. 

What I mean by the two statements is this : there is not in 
my opinion a single case of gonorrhea which if properly and 
skillfully treated and treated long enough could not be cured 
eventually. But there are about a million gonorrheal pa- 
tients to whom prolonged, proper and skillful treatment is 
an absolute impossibility, an unrealizable dream. They 
simply must go on with their lesion or lesions to the end of 
their days. Naturally, such are incurable cases. There 



114 GONORRHEA AND ITS COMPLICATIONS 

are a few chronic aggravated conditions to cure which might 
take a year or two at a cost of a hundred, five hundred or 
perhaps even a thousand dollars. Can the poor man or the 
average person afford it? But that does not mean that 
scientifically speaking such cases are not curable. But 
economic conditions are often at loggerheads with scientific 
medicine, and poverty often renders a disease, which is 
theoretically curable, practically incurable. 

So, there is nothing contradictory in the above two state- 
ments. 



CHAPTER XIX 

THE INSTRUMENTS USED IN THE TREAT- 
MENT OF GONORRHEA 

The instruments required for the proper treatment of 
gonorrhea are few in number. The general practitioner 
requires but very few indeed ; and even the specialist whose 
reputation is so well established that he is no longer in 
need of any tricks to "impress" the patient, can get along 
with a surprisingly small number. 

For instance, I find that a 100 c.c. syringe, a Guyon in- 
stillator, a set of sounds, a Kollmann dilator, and occasion- 
ally the urethroscope, are all the instruments I need in 90 
per cent, of all cases, the first two being sufficient in at least 
75 per cent, of all cases of acute and chronic gonorrhea. 
Specialists when writing for the general practitioner seem 
to be unable to resist the temptation to show off their great 
erudition, their remarkable skill and their armamentarium 
chirurgicum. I will present only what is actually needed, 
what is in daily use. 

THE PATIENT'S SYRINGE 

The first instrument we have to discuss does not really 
belong to the doctor's armamentarium, but is the patient's 
chief and only instrument. It would be better if the pa- 
tient did not have to use any injections on himself, hav- 
ing them all given by the doctor or an intelligent nurse ; but 

as this cannot be, and as for many years to come the home 

115 



116 GONORRHEA AND ITS COMPLICATIONS 



injection treatment will remain an important part of the 
treatment of gonorrhea, it is important to see that the 
patient gets the proper syringe. In fact the success of the 
injections often depends on the character of the syringe: 
its quality, size, action of the piston and ease, difficulty or 
impossibility of asepticization. 

To tell a patient, as doctors very often do : ' ' Here is a 
prescription for an injection, get a syringe and use it three 




Syringe for patients' use 






Soft Rubber Tips for Urethral Syringe 

times a day," is simply foolish, not to use a stronger word. 
The doctor must show the patient what kind of a syringe 
to buy, and must instruct him exactly how to use it. He 
must himself give him at least one injection, and then make 
the patient inject himself, so as to see whether or not he 
performs this little but important operation properly. 

The best syringe for the patient is one with a glass bar- 
rel, hard rubber mounting and soft rubber tip. It should 
hold three to four drams. If the patient's anterior ure- 



INSTRUMENTS USED IN TREATMENT 117 

thra is very small, he can fill the syringe only two-thirds 
full, or he injects one dram first and lets it run out, which 
acts as an additional safeguard against pushing germs from 
the anterior into the posterior urethra. It is necessary to 
see that the piston works smoothly and not in jerks, and 
that the syringe does not leak. 

I do not like the syringes with asbestos packing, for they 
often "stick." There is an all glass syringe on the mar- 
ket (aseptic), which theoretically is ideal, but it has the 
objection that the piston often refuses to work smoothly, 
and the barrel is apt to crack. 



Penis Clamp, put over the glans to retain 
injections for 10 or 15 minutes 

The patient may take the injection standing, sitting on 
the edge of a chair, or lying down. The steps are as fol- 
lows: The patient fills the properly kept and rinsed syr- 
inge. He then urinates, wipes off the glans and particu- 
larly the meatus with a piece of cotton dipped in a bichloride 
solution ; then he raises the penis, with his left hand, to an 
almost vertical position, opening the meatus with his thumb 
and forefinger, then takes the filled syringe, inserts the tip 
into the gaping meatus snugly, pressing it gently against 
the lips, so that the injected fluid may not run out ; he then 
presses the piston down gently but firmly and steadily, until 
he has injected about a dram (% of the contents of the syr- 
inge) ; he removes the syringe and lets this quantity run 



118 GONORRHEA AND ITS COMPLICATIONS 

out. He reinserts the syringe and injects the remainder; 
holding the thumb and the forefinger on each side of the 
meatus, he removes the syringe, and quickly compresses the 
lips, holding in the solution for five to seven minutes, when 
he voids it. He then rinses the syringe with plain water, 
and puts it in the bichloride solution ready for the next in- 
jection. Instead of compressing the meatus with the fingers, 
a penis clamp may be used. 

THE PHYSICIAN'S SYRINGE 

A syringe of 100 to 150 c.c. capacity (3% to 5 ounces) 
serves a number of useful purposes. It can be used for 




100 c.c. Syringe for doctors' use 

repeated injection of the anterior urethra, for washing out 
the anterior and posterior urethra, and for filling or ir- 
rigating the bladder. The best syringe for these purposes 
is the well known Janet-Frank syringe. It has a glass bar- 
rel, metal mountings, a hard composition packing, and a 
screw by which the working of the piston can be regulated. 
The syringe may be thoroughly sterilized by boiling. A 
soft rubber tip is used with the syringe. 

The Record syringes are also made now in large size — 
100-250 c.c. — but I do not find them so convenient. 



CHAPTER XX 

THE ABORTIVE TREATMENT OF 
GONORRHEA 

We come here to one of the most important questions con- 
fronting the genito-urinary specialist: Can gonorrhea be 
aborted? Is an attempt to abort gonorrhea justifiable? If 
the first question can be answered in the affirmative, it nat- 
urally follows that an affirmative answer must also be given 
to the second question. Gonorrhea is such a grave disease, 
its possible complications and sequelge are so serious and far- 
reaching, that a really effective abortive treatment would be 
a boon and a blessing and its discoverer would rank among 
humanity's benefactors. Unfortunately we are not yet in 
possession of a reliable and satisfactory abortive treatment, 
and it is a question if we ever will be. Not that we do not 
possess efficient bactericides which when brought in contact 
with the gonococcus will surely destroy it. But when the 
patients come to us the gonococci are no longer on the sur- 
face, on the free urethral mucous membrane, but have dug 
beneath the surface and are protected by several layers of 
epithelia from the action of the germicidal solution. We 
may in the future get a preparation which will penetrate 
deeply into the tissues, but so far such a preparation is not 
yet at our command. Another objection to the abortive 
treatment is that it is apt, in a large number of cases, to 
lead to serious complications, and to leave the patient in a 

119 



120 GONORRHEA AND ITS COMPLICATIONS 

much worse condition than when he applied for treatment. 
Casper says that he has seen cases of lymphangitis, lympha- 
denitis, prostatitis and cystitis develop under the abortive 
treatment, and in such a way that there could be no doubt 
as to the causal relationship between the treatment and the 
complications. We know personally of cases where an at- 
tempt at aborting gonorrhea with silver nitrate was fol- 
lowed by the most excruciating pain, profuse bloody dis- 
charge, terrible strangury and complete urinary retention 
for twelve and twenty-four hours. 

It must be conceded that the vast majority of genito- 
urinary specialists are opposed to the abortive treatment of 
gonorrhea: First, because it does not abort, except in a 
small percentage ; second, where it fails to abort the gonor- 
rhea is generally aggravated ; and third, it is apt to lead to 
painful and serious complications. 

I also am opposed to it,- as a general thing. And still 
there are special cases where we are fully justified in making 
an attempt to abort the disease, and in these special selected 
cases we are sometimes rewarded with brilliant successes. 
To illustrate. A. B., age 28, has had intercourse five days 
before, and for the last forty-eight hours has had an un- 
comfortable, "hot" and itchy sensation in the anterior por- 
tion of the urethra. This morning he noticed a small drop 
of discharge. By gentle pressure we succeed in expressing 
another drop, which when examined shows the presence of 
numerous unmistakable gonococci. (An examination of the 
woman the following day shows her to be suffering with a 
chronic gonorrhea.) He has had gonorrhea five years be- 
fore, but was completely cured, and his urine has been free 
from shreds. Even now the urine — not only the second but 



ABORTIVE TREATMENT 121 

also the first portion, with the exception of the first few 
drops — is perfectly limpid and free from shreds. To the 
suggestion that locally it would be best to wait a day or 
two, he replies no, that he must be cured as soon as possible, 
for he is to get married in two weeks. The possible dangers 
of an abortive course of treatment are explained to him, 
but he is willing to take all the risks. He is then treated 
with protargol, by the method to be here outlined; the dis- 
charge and the burning increase at first, but at the end of 
five days the man is completely cured; no discharge, no 
gonococci, the urine perfectly clear, and the marriage is 
followed by no disagreeable consequences whatever. 

Admitting then that there are cases in which an attempt 
at abortive treatment is justifiable and even indicated, what 
is the best method? Silver nitrate should never be used for 
the purpose. In weak dilutions it is inefficient, in strong 
solutions it is dangerous. Not that we may not succeed 
occasionally in aborting a case with silver nitrate, but the 
percentage of such smooth successes is so small and the 
danger of aggravating the trouble and causing painful com- 
plications is so great, that we have no right to use this 
method. Brutal and risky measures are occasionally suc- 
cessful, but that does not mean that we have a right to 
sanction them. 

There are several drugs that have been used in the abor- 
tive treatment of gonorrhea ; but we will not waste time in 
describing them all; we will limit ourself to the two with 
which we have had most experience ; they are protargol and 
argyrol. They are a strong enough silver salts, but the 
inflammation they produce is not strong enough to result in 
healing with cicatricial contraction. Now for the method : 



122 GONORRHEA AND ITS COMPLICATIONS 

The patient urinates and the anterior urethra is gently 
washed out with about four ounces of warm normal salt 
solution (7:1000). No force must be used, and not more 
than a dram or two of solution should be at any time in the 
urethra (so as to prevent any fluid from opening the cut-off 
muscle and penetrating into the posterior urethra), and the 
meatus should not be tightly closed by the tip of the syringe, 
so that the fluid may flow freely back. A few drops (5 to 
10) of a 4 per cent, solution of cocaine, eucaine or alypin 
are then instilled into the urethra. One dram of a 2 per 
cent, protargol solution is then injected, and by closing the 
meatus with the fingers held in for five minutes. In three 
hours a dram of a 1 per cent, solution of protargol is in- 
jected and held in for three minutes. This injection — 1 
dram of a 1 per cent, protargol solution held in for three 
minutes — is repeated every two hours until four injections 
have been given. The next four injections, at three hour 
intervals, are given with y 2 per cent, solutions ; and the next 
four injections, also at three hour intervals, are given with 
% P er cent, solutions. If we use argyrol, the method is the 
same, only the strength of the solution is different. The 
initial solution is 50 per cent. ? and the subsequent solutions 
25 or 20 per cent. 

The discharge is examined for gonococci every day. At 
the end of two or three days we know what we may expect. 
If the abortive treatment proves successful and the 
gonococci have disappeared or are becoming less and less, 
well and good. If not, then also well, though not so well ; 
at any rate we have not hurt our patient, and we may then 
proceed with the regular treatment of acute gonococcal 
urethritis. 



ABORTIVE TREATMENT 123 

When not to attempt the abortive treatment. — While 
there are differences of opinion among urologists as to 
whether abortive treatment should ever be tried or not, 
there is practically no difference of opinion as to when it 
should not be attempted. All agree that abortive treatment 
should not be attempted if the discharge, no matter how 
scanty, has lasted longer than forty-eight hours ; nor if the 
discharge is profuse and purulent, no matter of how short 
duration ; nor when the meatus is red, puffed and swollen ; 
nor when the glans is turgid ; nor when there is a consider- 
able burning on urination ; nor when there are the slightest 
signs of strangury ; nor when the patient is suffering with 
painful erections or chordee. It is too late then to attempt 
abortive treatment, and that's all there is to it ; and besides 
all the patient's symptoms are almost sure to become greatly 
aggravated. 



CHAPTER XXI 

THE PREVENTION OF GONORRHEA 

I confess that it is with a feeling of reluctance and dis- 
pleasure not unmixed with some disgust that I approach the 
task of writing this chapter.* I would like it much better 
if it did not have to be written. It would be infinitely 
better if things were so arranged in this world that no 
necessity existed for the use of venereal prophylaxis. 
Whether it would not be better for the world at large if 
people avoided illicit relations altogether, thus escaping 
practically all danger of venereal infection, is a question 
the discussion of which does not belong within the scope 
of this book. I discussed it elsewhere and shall discuss it 
again. But the fact remains that people do indulge and in 
spite of all preaching will indulge in illicit relations, not 
only antemarital but also extramarital. So the question 
arises: Should we refuse them any protection and permit 
them to infect themselves, carrying perhaps the infection 
to their wives and children, or should we teach them how to 
take care of themselves, so that the venereal scourge may 
eventually be limited instead of constantly increasing in ex- 
tent? I believe in the latter. The idea that illicit inter- 

* Logically, the chapter on prevention should precede the chapter 
on cure. Unfortunately, however, most men apply to us after they 
have gotten the disease, and not before, and to many physicians the 
subject of prevention of gonorrhea will possess but an academic in- 
terest. 

124 



THE PEEVENTION OF GONORRHEA 125 

course is a crime for which venereal disease is a well de- 
served punishment is entirely too mediaeval, too brutal to 
meet with my acceptance. Led to its logical conclusion, 
this idea would consider any physician who treats venereal 
disease a criminal, because by curing patients of their 
" deserved" diseases he encourages immorality. Only a 
man of the mental caliber of a mediaeval monk could sub- 
scribe to such a belief. The humanitarian physician must 
not only cure, he must prevent disease, and he recognizes 
that prevention is vastly more important than cure. 

I wish the remedies we do have were more satisfactory 
than they are ; then this book would not have to be written. 
Not that the remedies that we have are not efficient. But 
they are unesthetic, some of them are troublesome, and for 
these two reasons people will often neglect using them. If 
properly used the remedies may be said to be absolute pre- 
ventives ; but the trouble is that people will either not use 
them or use them improperly. Truthfully speaking, the 
fault is not in the prophylactics but in the people, but still 
if the remedies were pleasant and easy of application they 
would be used more certainly and more regularly. But 
there has been gradual progress in this direction, and we 
may perhaps see an unexceptionable prophylactic in the 
near future. 

The first principle of prophylaxis is personal cleanliness 
of the genitals. A person who seldom washes the glans 
penis and allows smegma to accumulate beneath his foreskin 
invites infection. The foreskin should be drawn back daily 
and it and the glans washed carefully with soap and water 
and dried. If there is a tendency to abrasions, washings 
with alcohol (1 part alcohol and 3 parts water) or with a 



126 GONORRHEA AND ITS COMPLICATIONS 

5 per cent, solution of alum should be resorted to. Of 
course no suspicious sexual relations should be had when 
there is the slightest abrasion on any part of the penis, and 
should the tendency to abrasions, or cracks, or pimples per- 
sist, a physician should be consulted. 

Circumcision is an important prophylactic measure, and 
the circumcised have a great advantage over the non-cir- 
cumcised in respect to venereal infection. While the im- 
portance of circumcision is more striking in avoiding 
chancre and chancroids, still it also plays a role in avoiding 
gonorrhea. For I am convinced that in many cases the 
gonococcus is not deposited immediately in the fossa navicu- 
lars, but in the preputial cavity, whence it wanders at its 
leisure into the urethra. The glans can also be much more 
thoroughly sterilized when the prepuce is absent than when 
it is present. 

A simple but in many cases efficient prophylactic 
measure is urination immediately after coitus. Many 
men use no other prophylactic and they seem to be 
safe. While of course it cannot be scientifically proven 
that without this precaution they would have contracted 
gonorrhea, still the fact that some men indulge in 
promiscuous intercourse for years without once contract- 
ing the disease is some presumptive evidence of its value. 
The stream of urine mechanically washes away the infective 
material ; and besides the urine, being of acid reaction, 
acidifies the urethral secretion, and this, as we know, is an- 
tagonistic to the development of the gonococcus. The man 
should have plenty of urine in his bladder (he should drink 
plenty of water and not urinate before coitus), and urinate 



i 



THE PREVENTION OF GONORRHEA 127 

immediately. The proper way is to start urinating, then 
to compress the meatus, and then suddenly let go. This 
dilates the urethra, and the stream coming 1 out with more 
force washes out the canal more effectively. 

If desired a dose of hexamethylenamine (5 grains) and 
monobasic sodium phosphate (about 30 grains in a glass 
of water) or sodium benzoate (15 grains) may be taken 
before coitus. This renders the urine more strongly acid 
and also perhaps somewhat antiseptic. 

The Condom. The oldest, simplest and at the same time 
safest protective against gonorrhea is the condom. This 
mechanical covering was invented by a Dr. Condom, who 
may well be considered one of the benefactors of the human 
race. It has no doubt since its introduction protected mil- 
lions of people from infection. Prof. Blaschko of Berlin 
has stated publicly that Dr. Condom deserves a monument, 
as without his little invention all civilized races would 
probably by this time be completely syphilized. The con- 
dom (also called French letter, protector, skins, capote 
anglais) is made principally of two materials: rubber and 
fish-skins (that is the swimming bladders of fishes). Each 
material has its advantages and disadvantages. The rubber 
is supple and elastic, fits better and does not easily slip off. 
But being a vegetable material it forms a barrier, and 
diminishes to a great extent the voluptas of the act. In 
some men it interferes with erection and ejaculation. And 
some men detest them so that they would rather forego all 
sexual relations than to use one. The skin condoms do not 
affect the act so much, but are not elastic, and must be 
moistened before use. Condoms are also made from the 



128 GONORRHEA AND ITS COMPLICATIONS 

cecum of sheep and they have the same advantages and dis- 
advantages of those of fish-skin.* Of course only the best 
quality of condom should be purchased, and one should 
make sure that the condom is perfect, by blowing it up or 
filling up with water before use. For the benefit of people 
in moderate circumstances it may be stated that condoms 
of good quality may be used more than once, but of course 
they must be cleansed and disinfected after each use. "Wash 
well in running water and then let it soak in a solution of 
mercuric chloride 1 : 1,000 for an hour or two, wipe and dry 
and put away wrapped up in gauze. 

Condom No Protection for Syphilis. While this book 
deals exclusively with gonorrhea, still I consider it a matter 
of duty to emphasize that while a good condom is a protec- 
tion against gonorrhea, it is not a protection against syphilis. 
I have had in my practice a number of cases of syphilis con- 
tracted by patients who used condoms. Not to mention the 
possibility of infection from mucous patches on the lips, 
which is self-evident, infection may take place either at the 
root of the penis or on the scrotum. Only this morning 
(March 19, 1915) I saw a patient, sent to me by Dr. R. I. 
Tillman, with a typical chancre at the root of the penis and 
a well developed roseola over the entire body. Some five 
weeks ago he had sexual relations with a prostitute. He 
used a condom, but the chancre developed at the very root 
of the penis, the part unprotected by the condom. We 
have no real reliable preventive against syphilis. 

Chemical Antiseptics. We now come to chemical anti- 

* We understand that at present all so-called fish-skins are made 
from the cecum of sheep, so that the correct term is really cecal 
condoms. 



THE PREVENTION OF GONORRHEA 129 

septics. One of the simplest and cleanest is a solution of 
mercuric chloride (corrosive sublimate) 1 to 5,000. Many 
men carry a small vial of this solution with them, and with 
a piece of cotton wash thoroughly the glans and squeeze a 
few drops into the open meatus. Some have told me that 
they had been using it for years without ever any accident. 
It is clean, cheap and does not stain the clothes. Some 
people, however, are sensitive to mercuric chloride and the 
solution causes some irritation on the glans or in the ure- 
thra. 

Others use a solution of potassium permanganate (1 to 
5,000) by injection. Guiard is particularly partisan to this 
method. About two to four drams is injected with a hand 
syringe, retained for a few minutes and let out, and the pro- 
cedure is repeated several times (5 to 10 times). This 
method is effective as a prophylactic, but I am not in favor 
of it. By injection the infecting material may be carried 
further backward, injections are irritating and may cause 
damage, and besides potassium permanganate stains the 
clothes and linen. The use of oxy cyanide of mercury would 
obviate the last objection, but there would still remain the 
objections inherent in all injections in the layman's hands. 
I have had several accidents from the use of injections and 
therefore do not recommend them. 

Protargol and argyrol have been used extensively and 
effectively as venereal prophylactics. A few drops of 
a 5 or 10 per cent, solution of protargol or 20 per 
cent, solution of argyrol are instilled into the urethra 
and held there for several minutes. In some cases a 
slight urethritis is caused by these strong solutions, but 
the urethritis is readily controlled, and weaker solutions are 



130 GONORRHEA AND ITS COMPLICATIONS 

used on future occasions or a different combination is sub- 
stituted. 

Silver nitrate is efficient, but is too irritating and I am 
opposed to its use. 

In the last few years, following Metchnikoff 's experi- 
ments, calomel in ointment form has been used a great deal 
as a prophylactic against syphilis. It has been found, how- 
ever, that the calomel ointment also acts as a preventive 
against gonorrhea and some advise the use of it as a general 
venereal prophylactic. The glans and prepuce is well 
rubbed in with the calomel ointment to prevent the de- 
velopment of syphilis and chancroids, and some of it is in- 
jected into the urethra and this prevents the development of 
gonorrhea. The preparation used, for instance, on the 
U. S. SS. Rainbow has the following formula : 

Calomel 50 gm. 

Liquid petrolatum 80 c.c. 

Adeps lanae 70 gm. 

This being a semi-liquid preparation, it can be injected 
with an ordinary urethral syringe. During a period of 
six months there were 529 admitted exposures, with the 
development of only four cases of gonorrhea. Of these four 
one denied exposure and therefore did not receive the treat- 
ment, two received it late, more than twelve hours after 
exposure, so that out of the 529 there is really only one 
failure, which, considering the character of the women with 
whom the sailors consort, is an excellent record. 

To avoid the inconvenience of having to prepare solu- 
tions, of carrying about a bottle and syringe, a number of 
prophylactics have been put on the market ? which have the 



THE PREVENTION OF GONORRHEA 131 

advantage of small compass, cleanliness, and readiness for 
use. Every country has its own preparations — in Germany 
there are dozens of them. Most of them contain 20 per 
cent, solutions or mixtures of protargol, some contain al- 
bargin, some oxycyanide of mercury: Viro, Selbstschutz, 
Samariter, etc. There are several in this country, but the 
best known are the Sanitubes (and the " K " packet) . Their 
use is very simple, and as full instructions for use accom- 
pany these preparations, there is no need of giving them 
here. 

Antiseptic Douches. Another very important measure, 
but one which does not concern the man, is for the woman 
to take a copious antiseptic douche (mercuric chloride 
1:5000) immediately before coitus, or as near before as 
possible. This measure alone properly used would act as 
an efficient prophylactic in a very large percentage of 
cases. I hesitate to say how large, but my opinion is in 
about 90 per cent. That it would also protect the woman 
against infection from the man is self-understood. Many 
prostitutes using this precaution go on plying their trade 
for years without acquiring any disease ; and on the other 
hand many prostitutes and semi-prostitutes who are dis- 
eased, by the simple method of using a copious douche be- 
fore coitus avoid giving infection and are thus able to keep 
their customers. It is for this reason that the professionals 
are often less dangerous than the "occasional" loose girls, 
because the former have the knowledge and the facilities 
for using prophylactic measures which the latter have not. 

The above are the positive measures for the prevention of 
gonorrhea. But he who wishes to avoid the disease must 
also listen to some negative advice. Besides several things 



132 GONORRHEA AND ITS COMPLICATIONS 

to do, there are also several things not to do. The most 
important of all Don'ts is: Don't drink any alcohol, in 
any shape or form. Alcohol is a great ally of venereal dis- 
ease. It has a doubly pernicious effect. It weakens the 
reasoning power, paralyzes the will, and thus causes the 
man to lose all prudence, making him tarry at the act or 
repeat it too many times, and prevents him often — by put- 
ting him into a deep sleep lasting several hours — from em- 
ploying any antiseptic measures. But besides this, alcohol 
by producing a congestion in the urethral canal makes it 
more vulnerable and more receptive to infective agents. If 
no alcoholic beverages were indulged in, there would be not 
only much less sexual indulgence, but also very much less 
venereal disease. Bacchus is not only the greatest friend 
of Venus, but also of Mercury (and should I say Silver?) . 

Another Don't is not to tarry too long in the act, not to 
attempt to prolong it unnecessarily, and not to repeat the 
act unless another antiseptic douche has been taken. The 
man who has studied anatomy can derive some benefit from 
the knowledge that the two most dangerous, because most 
frequently infected points in woman are the urethra and 
the cervix. The vagina is very rarely infected. Having 
this knowledge he should guide himself accordingly. 

As is seen, there is no royal road, no short cut, to venereal 
prophylaxis. Pronouncing a prayer or a shibboleth will 
not do it. Some care must always be exercised, some trouble 
cannot be avoided. But this is a small price to pay for 
freedom from venereal disease. 

To summarize : In order to avoid venereal infection the 
genital organs must be kept in a clean, healthy condition. 
A condom of the best quality is up to the present day the 



THE PREVENTION OF GONORRHEA 133 

surest and simplest prophylactic. As, however, it inter- 
feres with the voluptas of the act, some men not being able 
to obtain an erection or ejaculation, other measures become 
necessary. They are : immediate urination after coitus, and 
instilling into the urethra a solution or a mixture of pro- 
targol or argyrol or a soft ointment of calomel. The K 
Packets and the Sanitubes are trustworthy and can be 
recommended. (As a protection against syphilis, which 
subject, however, does not belong in this book, the glans 
and prepuce should also be well rubbed in with a strong 
calomel ointment.) The woman should always take a 
douche of bichloride of mercury before coitus. Alcohol in 
any form is injurious and should not be indulged in before 
coitus, nor should the act be unduly prolonged. Following 
out these instructions, a man may be pretty certain of never 
contracting any gonorrheal urethritis. 



CHAPTER XXII 

THE MINOR COMPLICATIONS OF 
GONORRHEA 

PHIMOSIS 

Phimosis is a term applied to a condition of narrowing 
of the opening of the prepuce, so that it cannot be retracted, 
and the glans penis cannot be uncovered. The term is de- 
rived from the Greek phimosis, which means muzzling, from 
phimos, a muzzle. It is quite an appropriate term, for in 
many instances the glans is effectually muzzled, so that the 
mouth of the penis, the meatus, cannot be seen or ap- 
proached, except with the greatest difficulty. 

The condition of phimosis is often congenital, occasionally 
traumatic, and frequently the result of the venereal dis- 
eases: chancres, chancroids, and urethritis. It is with the 
latter variety of phimosis that we are principally concerned 
here. 

This condition of phimosis is apt to supervene in pa- 
tients whose prepuce is generally somewhat narrowed, and 
in cases of hyperacute urethritis. The inflammation and 
resulting edema infiltrate the prepuce to such an extent 
that it cannot be retracted. The urethral discharge and a 
few drops of urine after each act of urination accumulate 
behind the prepuce, and frequently produce a balanitis and 

a balanoposthitis. In severe cases the meatus itself be- 

134 



MINOR COMPLICATIONS OF GONORRHEA 135 

comes corroded by the accumulated discharge. The suc- 
cessful treatment of urethritis in the presence of phimosis, 
especially of some severe degree, becomes impossible, and 
that condition must therefore first be removed. And be- 
sides the glans itself is in danger of ulceration and even 
sloughing. 

Treatment. Gentle measures are at first to be tried, and 
in 95 per cent, of cases they will succeed. If the patient 
can stay at home, he should soak the penis every hour, for 
fifteen minutes at a time, in a warm 25 per cent. Burrow's 
solution (Liquor Burrowi, 1 part, hot water 3 parts) or in 
a 1:1000 chinosol solution. He may at the same time in- 
ject some of the same solution beneath the prepuce. This 
will keep the glans clean and prevent the pus and urine 
from accumulating. If the patient cannot stay at home, he 
should wrap the penis, beginning with the glans, in band- 
ages dipped in the just mentioned solutions or in lotio 
plumbi et opii. The bandage should be changed three to 
four times a day. Injecting some sterilized sweet oil con- 
taining half a per cent, of salicylic acid between the prepuce 
and the glans will also prove an aid in retracting the 
prepuce. 

After the phimosis has been reduced, any pathologic con- 
dition that may be found, such as balanitis, ulceration, etc., 
should be treated by mild antiseptic applications, or cauter- 
ization. Anointing the glans with salicylic oil two or three 
times daily will act as a curative and also as a prophylactic. 

If these measures for some reason or other fail to produce 
the desired effect — the prepuce may be thickly indurated, 
there may be a lot of smegma and concretions, or from ulcera- 
tion the prepuce may have become adherent to the glans — 



136 GONORRHEA AND ITS COMPLICATIONS 

we must have recourse to operative measures. These meas- 
ures are circumcisiou and incision. Circumcision in a state 
of inflammatory phimosis I only mention to condemn. Be- 
sides the almost unavoidable danger of the infection of the 
wound, the long time required for healing, the cosmetic 
effect is generally bad. It is hard to judge of the proper 
amount of tissue to remove, and the result is an ugly scar, 
with either too little or redundant tissue. 

Of the incisions we have two kinds: either one dorsal 
incision or two lateral incisions. The dorsal incision has 
the advantage of being only one : it is better to have to deal 
with one wound than with two ; the lateral incisions, which 
give us two flaps, an anterior and a posterior, have the ad- 
vantage of giving us a more thorough access to the glans. 
The prepuce is washed thoroughly with a 1 :3000 bichloride 
solution, and the same solution, or one somewhat weaker 
(1:5000) is injected abundantly, by the aid of a long 
pointed syringe, between the prepuce and the glans. The 
line of the incision — either one on the dorsum or one on 
each side — is infiltrated with a local anesthetic solution 
(cocaine, alypin, eucaine or novocaine; see formulas for 
infiltration anesthesia) and the cut is made with a bistoury 
or a pair of scissors. The cut wound is compressed with 
some gauze saturated in a 1 :5000 bichloride solution until 
the bleeding has stopped. It is best not to put in any 
stitches, unless the bleeding makes it absolutely necessary. 

AVhen the acute condition has subsided, then circumcision 
may be performed. 



MINOR COMPLICATIONS OF GONORRHEA 137 

PARAPHIMOSIS 

Paraphimosis is the opposite of phimosis; it is a term 
applied to a condition in which the prepuce is caught be- 
hind the corona of the glans, at the coronary sulcus, and 
cannot be pulled forward over the glans. It surrounds the 
penis like a tight cord. This condition may become very 
dangerous, as the glans becomes puffy, edematous, cyanotic, 
and unless relieved may become gangrenous. It may also 
be extremely painful, and interfere with micturition. For- 
tunately most cases are easily reducible by the experienced 
physician. By digital manipulation alone, the glans penis 
may be so compressed as to squeeze out all the edematous 
infiltration and the blood, and then by anointing with some 
fatty lubricant the prepuce is easily slipped over. Or a 
narrow rubber bandage is wound tightly over the penis, 
beginning with the glans, and in a very short time the 
edema is reduced and the glans slips in. 

In no case of paraphimosis within my experience have I 
had to have recourse to operative measures, though in some 
cases quite a good deal of manipulation was required before 
reduction was effected. But there are neglected cases, in 
which the patient has permitted the condition to exist for 
several days before he applies for medical aid, in which 
the strangulated tissues become plastically indurated; and 
passing the hardened edematous glans through the hardened 
infiltration of the constricting prepuce becomes an impossi- 
bility. The only thing to do is to incise the constricting 
band, in the median line, on the dorsum of the penis. In- 
troduce a bistoury flat under the constricting band, then 
turn it and cut. 



138 GONORRHEA AND ITS COMPLICATIONS 

If when the patient comes to you, you find the glans 
strongly cyanotic, almost black, cold and turgid, and with 
diminished sensibility, then not much time should be lost. 
An attempt at reduction by manipulation should be made, 
but this failing, not much time should be lost before in- 
cising the constricting band. 

After the reduction of the paraphimosis, the glans and 
the preputial cavity should be treated gently. Irrigation 
with a mild antiseptic solution, or the application of a mild 
antiseptic ointment, is indicated. 

BALANITIS 

Balanitis is an inflammation of the glans penis. It is de- 
rived from the Greek word balanos, which means acorn, and 
refers to the shape of the glans. It is often accompanied 
with, or is the result of, phimosis and paraphimosis, but may 
occur independently as the result of coitus with a woman 
having a nasty irritating discharge. Where the glans is 
simply inflamed, or covered with a whitish ointment-like 
secretion, we call it simple balanitis; where it is accom- 
panied with ulcerations, we apply the term ulcerative bal- 
anitis. 

The treatment consists in cleanliness, washing with hy- 
drogen dioxide or 1 per cent, resorcin solution, applying 
compresses of chinosol 1 :1000 solution, or bismuth subgallate 
powder, or an ointment of the following composition : 

IJ Zinci oxidi 3ii 

Bism. subnitratis 3i 

Ac. salicylici gr. x 

Petrolati albi %i 



MINOE COMPLICATIONS OF GONORRHEA 139 

When the inflammation is of a deeper grade, or is accom- 
panied with ulceration, cauterization by means of a 5 per 
cent, silver nitrate solution or 5 per cent, copper sulphate 
solution may become necessary. It should be taken as a 
rule that on a circumcised glans we can use stronger solu- 
tions than on a non-circumcised one. In the latter case, 
edema with a consequent phimosis is apt to result. 

Posthitis is an inflammation of the prepuce. (From the 
Greek, posthe — prepuce.) 

Balano-posthitis is applied to an inflammation of both the 
glans and the prepuce. 

The treatment of posthitis and balano-posthitis is prac- 
tically the same as that of balanitis. 

Here we have three affections — phimosis, paraphimosis 
and posthitis — which can be completely avoided by timely 
circumcision. Balanitis is also a much rarer and a much 
milder affection in the circumcised than in the non-circum- 
cised. And he who has seen some severe cases of phimosis 
and paraphimosis — which threaten the very integrity of the 
male organ — will not have much doubt that the law-giver 
who ordained the circumcision of all male infants was also 
a pretty good hygienist. And the fact that more and more 
people, outside the Jewish and Mohammedan races, subject 
themselves to circumcision points to the conclusion that the 
hygienic utility of this measure is becoming universally 
recognized. 

ADENITIS. LYMPHADENITIS (Inguinal 
adenitis. Bubo) 

In severe cases of urethritis, particularly when the pa- 
tient is obliged to do a good deal of walking and lifting, 



140 GONORRHEA AND ITS COMPLICATIONS 

the inguinal glands are apt to get inflamed and swollen. 
The complication is, however, not a very frequent one, and 
the swelling but very seldom proceeds to suppuration. It 
may be safely asserted that whenever suppuration does take 
place it is due to mixed infection. I have not had a single 
case of gonorrheal bubo terminate in pus formation. 

The treatment is : Put the patient to bed, apply hot com- 
presses of Burrow's solution for a few hours, afterwards 
apply a ' ' resolvent ' ' ointment. 

One of the following ointments is satisfactory : 

5 Ung. hydrargyri 3ij 

Guaiacoli 3i 

Ung. belladonna?, q. s. ad gi 

I> Plumbi iodidi 3i 

Ung. potassii iodidi gi 

If the patient cannot go to bed, the same ointment should 
be thickly applied, covered with cotton and oiled silk, the 
whole held in place with adhesive plaster. The application 
of a few overlapping strips of adhesive plaster (without the 
ointment) over the swollen glands is also beneficial. 

Lymphangitis or inflammation of the lymphatic vessels of 
the penis is rare, but does occur in superacute urethritis, 
and is to be treated by rest and cold compresses of diluted 
solution of aluminium acetate. 

Spongeitis is inflammation of the corpus spongiosum, and 
cavernitis is inflammation of the corpora cavernosa. As 
complications of gonorrhea they are very rare. When they 
do occur, they are to be treated with compresses — hot or 
cold — of diluted aluminium acetate solution (1 to 3). 

Periurethritis is an inflammation of the tissues surround- 



MINOR COMPLICATIONS OF GONORRHEA 141 

ing the urethra. As a rule it is circumscribed and the 
abscess may point and open through the penile skin. If the 
abscess is not incised but allowed to burst, a fistula may re- 
main. A fistula is more likely to be the result if the abscess 
is near the frenum. 

Cowperitis is an inflammation of one or both of Cow- 
per's glands. It may point and burst in the perineal re- 
gion, on either side of the raphe, between the scrotal junc- 
tion and the anus. It may be felt as a round swelling, the 
size of a pea to that of a hazel nut. 

Treatment. When the mass feels indurated without any 
sign of fluctuation, all measures should be taken to prevent 
suppuration. The measures are : massaging and expressing 
the gland into the urethra (when its excretory duct is open) , 
copious irrigations of the urethra with potassium perman- 
ganate solution (1:4000), rubbing in a resolvent ointment 
over the perineal region, or painting the latter with tincture 
of iodine, or applying to it two or three leeches. But when 
suppuration is present, or is inevitable, it is best to incise 
the abscess, irrigate it and drain it, as we thus avoid a 
troublesome perineal fistula. 

PAINFUL ERECTIONS AND CHORDEE 

It is natural that the congestion and irritation of the 
urethral canal should be the cause of frequent and pro- 
longed erections. These are sometimes the bane of the pa- 
tient and are the most disagreeable and most painful feature 
of his gonorrheal attack. While they are most frequent at 
night, they do occur quite frequently in the daytime, and they 
may be exquisitely painful. If frequent and persistent in 
the daytime, they put the patient in an embarrassing posi- 



142 GONORRHEA AND ITS COMPLICATIONS 

tion, so that he may find it difficult to attend to his work in 
the office, store or factory. In the nighttime the erections 
are frequently accompanied by pollutions, which are slug- 
gish, the semen oozing out slowly, and the urethral inflam- 
mation being aggravated by them. The erections fre- 
quently aggravate the gonorrheal inflammation, and retard 
the cure. A vicious circle is established, as is so frequently 
the case in disease. The urethral inflammation causes the 
erections, and the erections aggravate the inflammation. 

The term chordee is sometimes applied to these erections, 
but this is incorrect. The term chordee is properly applied 
only to erections accompanied by a curving of the penis 
downward. Sometimes the glans alone is pulled downward, 
sometimes the whole penis is arched in a semi-circle, almost. 
It is this variety of erection which is the most exquisitely 
painful, and is accompanied by slight hemorrhages, due to 
the stretching and tearing of the urethral mucous mem- 
brane. It is so painful that the patient in his agony — and 
in his foolishness — breaks it. That is, knowing of no 
remedy and unable to bear his suffering, he lays the penis 
on a table or a window sill and deals it a violent blow with 
the fist. It breaks the chordee, but it also breaks the penis, 
tears the urethra, and this is accompanied by bleeding — 
sometimes severe — and the formation of a stricture. 

Treatment. This, as all other complications of gonorrhea 
(as well as of any other disease) should be prevented if 
possible, and the anodyne, demulcent, antiphlogistic rem- 
edies which we administer for the gonorrhea also act in the 
direction of preventing or diminishing painful erections, 
pollutions and chordee. But when these complications are 
present, we must use some additional measures. Dipping 



MINOR COMPLICATIONS OF GONORRHEA 143 

the penis in hot water, as hot as can be borne, or water con- 
taining some lead and opium wash (solutio plumbi et opii 1 
part, hot water 7 parts), or a warm sitz bath (100° F. grad- 
ually raised to 115° or 120°) for 5 to 10 minutes, act as 
a prophylactic. But when the erection or chordee is actu- 
ally present, then dipping the penis in ice cold water, or 
wrapping it in an ice cold compress, or surrounding it with 
pieces of ice, is more efficient. A sixtieth of a grain (1 
milligram) of atropine sulphate taken before going to bed 
is frequently quite effective in preventing any erections. 
Sometimes it is not. And then we have to give bromides, 
much as I dislike them. Potassium bromide is the most 
efficient, but only because it is the most depressant. And I 
like it least of all the bromides. I generally prescribe the 
strontium and sodium bromides — 30 grains of each per dose. 
Less will hardly have any effect. The Burroughs-Wellcome 
effervescent tabloids of triple bromides make an agreeable 
form of administration, and are to be preferred when we 
have to deal with delicate stomachs. Lupulin, mono- 
bromated camphor and hyoscyamine are also efficient. 
Sometimes we must in addition to these also prescribe some 
morphine, but only in the form of a suppository. Here are 
the most efficient prescriptions for the purpose : 

IJ Lupulini, gr. v 

Camphorge monobrom, gr. iij 

Hyoscyaminse hydrobrom, gr. % 

M.f. caps. No'. 1. Tal. dos. xij 
S. One before going to bed. 

In obstinate cases an additional capsule may have to be 
taken an hour before going to bed. 



144 GONOERHEA AND ITS COMPLICATIONS 

If Morphine sulph., gr. % 
Ext. belladonnse, gr. % 
01. theobromas, gr. xxv 
M.f. suppos. No. 1. Tal. dos. vi. S. Insert one on 
going to bed. 

RETENTION OF URINE 

It does occur occasionally in the course of an acute 
urethritis that the patient finds himself unable to pass 
urine. This may be due to a sudden exacerbation of the 
inflammation in the posterior urethra, in the prostate, in 
the seminal vesicles, to an inflammation of Cowper 's glands, 
or to the fact that the patient had from before a slight stric- 
ture. The inflammation and the edema around the stricture 
occlude the lumen of the urethra and make it impermeable to 
the urine. Not infrequently such a retention of urine oc- 
curs after the not too gentle passing of a sound or bougie 
or a forcible or too strong injection. Under the latter cir- 
cumstances, the retention may also occur in the course of 
a chronic urethritis. 

The treatment of this condition, which is very uncom- 
fortable and if lasting too long may of course become 
dangerous, should be of the very simplest kind. A hot bath, 
the patient attempting to urinate in the water, is often effec- 
tive. Keeping the penis in hot water may also prove effec- 
tive. If these measures fail, the injection of a pint of hot 
water into the rectum generally succeeds. In attempting 
to pass the water from the bowel, the urinary sphincter also 
relaxes and the patient urinates. A good dose of fluid ex- 
tract of hyoscyamus (5 to 10 minims!) is also useful. 
Where these measures fail, we must catheterize the patient, 



MINOR COMPLICATIONS OF GONORRHEA 145 

using a soft catheter, well lubricated with warm sterile oil. 
The urethra should first be anesthetized with alypin and 
adrenalin. And I might add that the mere anesthetization 
of the urethra, by reducing the acute congestion, the 
strangury, and the fear of pain, will often make urination 
possible, and thus render catheterization unnecessary. If 
you do not succeed in passing a soft catheter, then you have 
a different case to deal with than a simple spasmodic con- 
traction, an inflammatory edema or nervousness. And the 
case is to be handled like retention resulting from stricture, 
by passing a steel catheter, by gradual dilatation, by passing 
filiforms, or by puncturing the bladder, by means of trocar 
and cannula. 



CHAPTER XXIII 
ACUTE PROSTATITIS 

Acute prostatitis is unfortunately a rather frequent com- 
plication of gonorrhea. There is a great difference in the 
opinions of venereologists as to the frequency of it, some 
putting it as low as 3 per cent., others as high as 92 per 
cent. This apparently absurd difference is really more 
apparent than real, some applying the term prostatitis to 
the mildest inflammation of the prostate, even of a catarrhal, 
transient character, others applying the term only to sup- 
purative prostatitis and prostatic abscess. 

If we apply the term prostatitis to every mild congestion 
or inflammation of the prostate, then we might consider it a 
natural accompaniment of every case of posterior urethritis. 
If we apply the term, however, only to those cases which 
give decided subjective symptoms and are accompanied by 
an unmistakable enlargement of the prostate, then I would 
say that the frequency is about 20 per cent. I consider it 
absurd, however, to apply the term acute prostatitis only to 
those cases in which the prostate is severely suppurating, 
or to consider acute prostatitis synonymous with prostatic 
abscess as some do. Even a prostate which secretes pus in 
profusion is not a prostatic abscess. When the urethra 
secretes pus profusely we use the term urethritis and not 
urethral abscess. As long as the ducts of the prostate are 
open, so that the pus finds its way readily into the urethra, 

146 



ACUTE PROSTATITIS 147 

we have no right to speak of prostatic abscess. It is only 
when the prostatic ducts become clogged so that the pus 
accumulates in the prostate, and there is perhaps destruc- 
tion of tissue, that we have a right to speak of prostatic 
abscess. 

I said at the beginning that prostatitis is unfortunately 
a rather frequent complication of gonorrhea. Of course 
every complication is unfortunate, but prostatitis is par- 
ticularly so, because it is that complication which makes 
chronic gonorrhea one of the most obstinate, sometimes one 
of the most maddening, conditions to treat. Any gonorrhea 
in which the prostate is not involved is comparatively 
readily curable, for applications to the urethral canal are 
readily made and by the modern methods of dilatation-irri- 
gation, and by massage, aided perhaps by vacuum treat- 
ment, we can lure the gonococci from their hiding places 
and destroy them, but once the gonococci penetrate the pros- 
tate then we have an entirely different condition to deal 
with. We cannot apply medication directly to and into 
the prostate, by no method of massage can we be sure to 
express every little subdivision and duct of the prostate, 
and I am sure that it was the infection of the prostate that 
made Bicord say that we knew when a man got gonorrhea 
but only the Lord knew when it would be over. 

Besides the much more hidden and labyrinthine recesses 
which the prostate presents to the germs, the latter seem to 
find a richer soil in it than they do in the urethra and the 
urethral glands, and for this reason it becomes so hard to 
dislodge them. All those long dormant cases in which the 
man was free from any symptoms for years, a gonorrheal 
attack suddenly coming on after drinking or sexual inter- 



148 GONORRHEA AND ITS COMPLICATIONS 

course, are cases of prostatic infection. The prostate is 
the germ's best hiding-place, and just as epididymitis is the 
most important complication as far as the race is concerned, 
so prostatitis is the most important complication so far as 
the wife is concerned, for infection of the wife usually re- 
sults not from an uncured urethritis but from an uncured 
prostatitis. 

SYMPTOMS 

The advent of acute prostatitis may be very gradual, so 
that the patient has practically no subjective symptoms, or 
perhaps only an aggravation of the symptoms caused by his 
posterior urethritis. He may feel greater discomfort in the 
perineum, a sense of weight and dragging down, difficulty 
in sitting, an inclination to walk with spread legs, etc. Or 
the attack may come on very violently. He will feel a 
terrible weight and heat in the rectum, become feverish, 
have perhaps a chill. In a severe acute prostatitis the tem- 
perature may go up as high as 103 or 104. The patient is 
constipated, and if he moves his bowels the pain may be 
excruciating. The urethral discharge, if it was present 
before, frequently stops entirely, though this is not so fre- 
quently the case as it is with epididymitis. Mere touching 
of the perineum is painful, while the pain caused by inserting 
the finger in the rectum and touching the prostate is un- 
bearable. 

The prostate feels hot, throbbing, hard, tense, and fills out 
the entire rectal cavity, sometimes to such an extent that 
defecation is not only painful but impossible in some cases. 
By sweeping the finger around the prostate you have ex- 



ACUTE PROSTATITIS 149 

actly the same sensation as in examining the vagina during 
labor when the child is at the outlet of the pelvis. 

Besides difficult defecation, pain on urination, or partial 
and sometimes complete retention of urine, the pain is 
severe not only on pressure but is spontaneous, and the 
patient asks for relief, which in some instances can be af- 
forded only by morphine. The pain instead of being located 
in the perineum and rectum may also radiate to the small 
of the back, to the glans penis, testicles and thighs. In- 
stead of being uniformly enlarged only one-half of the pros- 
tate may be swollen, the other half being almost normal. 

After lasting for several days in about the same condition, 
a prostatitis may pursue one of three courses. (1) It may 
end in complete resolution; (2) it may end in an abscess; 
(3) it may pass gradually into chronic prostatitis. Neither 
the first nor the second termination is very common, the 
most common one is the third. 

TREATMENT 

Put the patient to bed. As a rule we find him there, but 
if we do not we should make him go there. Local treatment 
of the urethra should be stopped, though this is not so im- 
perative as it is in epididymitis. The internal treatment on 
the contrary, however, should be continued. Unless the 
patient is so sick that his stomach cannot stand anything, 
the santal oil preparations should be continued. They 
diminish the dysuria, render the urine bland, and have ap- 
parently a beneficial effect on the prostatitis itself. 

Magnesium sulphate, in dram to two dram doses four 
times a day, should be given regularly. This prevents con- 



150 GONORRHEA AND ITS COMPLICATIONS 

stipation, has a beneficial effect on the fever and the toxemia. 
If the fever is above 101 or 102 and there is severe head- 
ache, I invariably give some of the synthetic antipyretics, 
such as aspirin, phenacetin, antipyrin or pyramidon. 
These not only have a symptomatic effect in reducing the 
fever, relieving the headache, and making the patient feel 
altogether more comfortable, but they also diminish the 
pain in the prostate and materially shorten the course of 
the disease. In severe cases of prostatitis we can but ill 
get along without any antipyretics. If the pain in the 
prostate is so severe that the patient is unable to sleep, 
restlessly tossing about day and night, we are forced occa- 
sionally to give a hypodermic of morphine, though I prefer 
to give the morphine in the form of suppositories, as fol- 
lows : 

^ Morphinae sulphatis gr. J 

Ext. belladonnae gr. J 

01. theobromae gr. xx 

Less than a third of a grain of morphine has no effect on 
a real case of acute prostatitis which demands an anodyne. 

Leeches to the perineum are favored by many physicians 
and frequently give immediate relief. I believe, however, 
that we can get along without them. Ice to the perineum 
is comforting and not injurious. When it comes to rectal 
douches, however, I prefer hot water to cold. The resolu- 
tion seems to be brought about more rapidly by the use 
of heat than by the use of cold. It is true that when a 
prostatitis is to terminate in an abscess the hot water 
enemas or applications by means of the psychrophore will 
hasten this often, but this is no misfortune, for if an 



ACUTE PROSTATITIS 151 

abscess is to take place and to break, the sooner it is done 
the better. The hot water to the prostate may be applied 
as an ordinary enema, about 6 ounces, containing 10 drops 
of laudanum and 10 grains of antipyrin, being injected and 
retained for about ten minutes; or it may be applied by 
means of the rectal psychrophore, hot water being cir- 
culated for about ten minutes. 

Suppositories of mercurial ointment and ichthyol have 
often been recommended and used, and I have used them 
many times myself, but they irritate the rectum badly, 
sometimes very badly, and the benefit derived from their 
use seems to be too small to outweigh the damage. I have 
therefore given them up altogether, and the only supposi- 
tory that I use in acute prostatitis is the following: 

5 Iodoformi gr. ij 

Antipyrini gr. v 

Morphinge sulphatis gr. J 

01. theobromae gr. xx 

Sig. One 3 times a day. 

The morphine of course has a tendency to constipate, but 
this is overcome by the magnesium sulphate which is ad- 
ministered through the course of the disease. 

Some of our German colleagues advise starting with mas- 
sage as soon as the hyperacute symptoms have subsided. I 
am opposed to it in any stage of acute prostatitis, as it may 
produce an exacerbation of the trouble or may set up an 
epididymitis. Massage of the prostate is distinctly a meas- 
ure reserved for chronic conditions of the gland. Of course 
if there are boggy, fluctuating places in the prostate which 
on gentle pressure produce a discharge of pus into the 



152 GONORRHEA AND ITS COMPLICATIONS 

urethra, such expression may be performed, but this is 
really a different procedure from what we ordinarily un- 
derstand by massage. If by gently pressing the prostate 
we are able to express pus into the urethral canal we should 
do it twice or three times a day, following this procedure 
by a very gentle irrigation with 1-4000 potassium per- 
manganate or 1-1000 silver nitrate. 

PROSTATIC ABSCESS 

If prostatitis is to terminate in an abscess all the symp- 
toms we described become aggravated. There is a great 
elevation of temperature, though some prostatic abscesses 
without fever have been described. There is a great in- 
crease in the heat, pain and throbbing of the prostate. 
There is excruciating dysuria, headache, thirst, dry throat, 
and there may be complete retention. 

The prostate may break into the urethra, or into the 
rectum, or into the perineum. Sometimes it breaks in 
both directions, into the urethra and the rectum or per- 
ineum, thus forming a urethral or urethro-rectal fistula. 
When the abscess breaks spontaneously into the urethra 
there is a great gush of pus, generally mixed with blood, 
and this happy event is followed by almost immediate 
diminution of all the symptoms. 

If the abscess does not break within a day or two 
and the fever goes up high, the best thing to do is to 
incise the prostate through the perineum. But if the 
prostate points into the rectum and there is a distinct 
fluctuating mass felt by the finger, then it is best for the 
physician to incise the prostate through the rectum. 

The rectum may be irrigated with an antiseptic or simple 



ACUTE PROSTATITIS 153 

saline solution until it is absolutely free from any fecal mat- 
ter, then a bistoury is plunged directly into the fluctuating 
mass, and the prostate is expressed as much as possible. 
The healing is less troublesome than when the incision is 
made through the perineum, and this method will be the 
one which the general practitioner will choose. 

As we said before, an acute prostatitis may end in two 
or three weeks in complete resolution, so that there is ap- 
parently no sign left of the inflammation. As a rule, 
however, the symptoms subside gradually and the acute 
prostatitis passes over into subacute or chronic prostatitis, 
the discussion of which will be taken up in the next 
chapter. 



CHAPTER XXIV 
CHRONIC PROSTATITIS 

Chronic prostatitis is a very common condition. In a 
greater or lesser degree it is present in a very large per- 
centage of the male population of every civilized country. 

Causes. One of the most important factors in the etiol- 
ogy of chronic prostatitis is gonorrhea, but gonorrhea does 
not play the same relative role in the causation of chronic 
prostatitis that it does in the causation of acute prostatitis. 
In the latter gonorrhea is by far the principal factor; other 
causes play but a subordinate role. This is not so in 
chronic prostatitis; while, as we said, gonorrhea does play 
a very important role, other factors are also of great im- 
portance. Among those factors we may enumerate chronic 
urethritis of whatever origin; masturbation; sexual ex- 
cesses (that is, too frequently repeated natural sexual inter- 
course) ; coitus interruptus; complete abstinence, partic- 
ularly if accompanied with excitation, mental or physical, 
without gratification (it is remarkable how the over-use, 
abuse, or non-use of a function frequently leads to the same 
result) ; a steady, long-continued sedentary life; catheter- 
ization ; stricture ; and long-continued cystitis. 

A chronic prostatitis following a gonorrhea, or other 

forms of urethritis, may be chronic from the very start or 

it may be the end stage of an acute or sub-acute prostatitis. 

154 



CHRONIC PROSTATITIS 155 

Symptoms. The symptoms of chronic prostatitis may 
vary from the mildest to extremely severe. There are cases 
of prostatitis which are symptomless, or practically symp- 
tomless, and there are cases which assume the character of 
a very serious malady. 

It might be asked how we know that a man has prostatitis 
if it gives him no symptoms whatever. Of late years a good 
many men before getting married, or even before becoming 
engaged, come to the physician for a sexual examination. 
They tell him that they feel all right in every way, that 
there is absolutely nothing the matter with them, but that 
they want him to make sure that they are all right. Some 
of them may have had a gonorrhea, some of them have abso- 
lutely no venereal history. In a certain percentage of these 
men who complain of no symptoms whatever we find on 
examination distinct evidences of prostatitis. The prostate 
is either enlarged and "boggy," or only boggy, and on ex- 
pression we obtain a fluid which gives unmistakable evi- 
dences of a mild grade of inflammation. 

Pathologically, the condition in the prostate may vary 
from a simple congestion to an extensive suppuration. In 
the majority of cases, however, the symptoms of prostatitis 
are pronounced, and may be classified as local, sensory, 
urinary, sexual, and general nervous 

The local symptoms are those that we discover by an 
objective examination. The prostate is usually enlarged, 
soft, boggy ; either soft throughout or soft in some spots and 
hard and nodular in others, more than normally sensitive 
on pressure, and exudes a turbid lumpy secretion on expres- 
sion. 

The sensory symptoms are heaviness and a dragging sen- 



156 GONORRHEA AND ITS COMPLICATIONS 

sation in the perineum, pain in the prostate and perineum, 
and pruritus ani or itching around and within the anus. 
The patient cannot sit comfortably for any length of time 
in one place and likes to shift his position. A symptom that 
can be frequently observed by the careful observer is that 
the patient when sitting down will sit on the edge of the 
chair, and if the chair permits it, on one buttock only. 
Walking is less annoying to him than sitting or standing. 
He feels most comfortable lying down. While the pain may 
be limited to the prostatic region, it may, as is easy to un- 
derstand with an organ so rich in nerves as the prostate, 
radiate to various parts of the body, to the testicles, urethra, 
penis, thighs, and small of the back. The pain may also 
radiate to the kidneys and simulate the pain of renal colic. 
Personally, however, I have not seen such cases; in renal 
colic the pain is too acute, too sharp, to be mistaken for the 
dull, gnawing pain of prostatitis. Still some authorities 
claim to have seen such cases. 

A very frequent and most annoying symptom is a leaden 
heaviness in the calves of the legs, and also a burning in 
the soles of the feet. These symptoms make themselves par- 
ticularly noticeable in the afternoon, around four o'clock. 
I have been able to diagnose prostatitis in a great number of 
cases from these two symptoms alone. With the cure of 
the prostatitis these symptoms disappear. 

The Urinary Symptoms. — One of the most common 
symptoms is the frequency of urination. The patients may 
have to urinate every two hours or every hour, and if they 
happen to drink some irritating liquid like beer, may have 
to urinate every fifteen or twenty minutes. They also have 
to get up in the night from one to four times. Another 



CHRONIC PROSTATITIS 157 

symptom is the urgency of urination. There is a difference 
between frequency and urgency. A person may feel like 
urinating frequently, but if he is unable to urinate at a 
certain time it may cause him no effort to retain his urine ; 
in the case of urgency, however, when the desire to urinate 
comes on it must be complied with instantly or the patient 
is apt to wet his underwear. There is a disagreeable, per- 
haps scalding, sensation on urinating, and there is drib- 
bling of urine after the act. The size and character of the 
stream is often unaffected, though as a rule it is smaller 
than usual. The urine itself is frequently turbid, and con- 
tains many bacteria and a large amount of phosphates ; in 
fact, phosphaturia is one of the most common symptoms in 
prostatitis. Whether it is a direct result of the prostatitis 
or whether it is caused by the nervous condition induced by 
the prostatitis is an open question. 

The sexual symptoms are briefly summarized in imperfect 
erections and premature ejaculations, The libido may be 
diminished, but as is so often the case whenever any irrita- 
tive condition exists in the prostate, may be greatly in- 
creased, causing the patient to indulge to excess, thus still 
further aggravating his condition. 

The general and nervous symptoms produced by an irri- 
tated or inflamed prostate are literally legion. First there 
is a general irritability, a physical and psychic irritability. 
The patient responds much more quickly to external stimuli, 
such as changes in temperature, and he gets very easily 
upset over little things. Then there is a general depression. 
This depression expresses itself not only in a lack of desire 
for work and a lack of interest for things, but in a general 
despondency. The patient may occasionally become deeply 



158 GONORRHEA AND ITS COMPLICATIONS 

melancholic, and this to such an extent that he may harbor 
suicidal ideas. If the condition lasts long he may become 
a victim of sexual neurasthenia, with its legion of symptoms, 
but to discuss the latter here would lead us too far and we 
must refer the reader to special books on the subject. 

TREATMENT 

While prostatitis, as we have seen, may be a serious com- 
plication, giving rise to numerous annoying symptoms which 
make the patient wretched, diminish or destroy his useful- 
ness, and may even lead him to suicide, there is one bright 
feature about it, and that is that it is very amenable to 
treatment. 

While we may not change the secretion in a suppurating 
prostatitis to such a degree that it does not contain a single 
pus cell, still practically all cases of prostatitis (and it is 
quite safe to leave out the word practically) may be im- 
proved to such an extent that they will give no symptoms 
and the patient will not be aware of their existence. 

The treatment of prostatitis, as of all diseases of the 
genitourinary organs, is both general and local. The pa- 
tient must guard against constipation. The diet must be 
bland, strong spices and condiments being eschewed, alco- 
holics must be reduced to a minimum, and everything must 
be done to raise the general condition of the patient from 
below par to par or above par. Cool baths and douches are 
useful for the general system, but hot sitz baths are neces- 
sary for the prostatic condition. It goes without saying 
that any pathological condition in the urethra, such as a 
posterior urethritis, or a stricture, or colliculitis, or a sem- 
inal vesiculitis, must be treated concomitantly. 



CHRONIC PROSTATITIS 159 

Prostatic Massage. There is one measure, however, 
which is more important in the treatment of chronic prosta- 
titis than all other measures combined, and that is massage 
of the prostate. 

% It is quite remarkable what rapidly beneficial effect a 
massage of the prostate will produce on the patient's condi- 
tion, both local and general. It constitutes one of the most 
gratifying methods of treatment in the venereal specialist's 
work. Without the patient being told what the massage 
was for, what it was expected to accomplish, he will either 
at once or at the next visit volunteer the statement that he 
felt immediately better, that not only did he feel an improve- 
ment within the rectum and perineum, but he felt generally 
better. In fact, even a mere examination of the prostate, 
in which you sweep the finger around the gland to determine 
its contour, size, and consistency, and in which you do 
hardly any expression, produces a beneficial effect. There 
is no exaggeration in saying that the effect of prostatic 
massage is often simply marvelous. 

While we are more interested in facts and in the effects 
of certain treatment than in the explanations of the why and 
wherefore, still the reasons for the strikingly beneficial effect 
of prostatic massage have always been of great interest 
to us. And while we can pretty well explain the 
rationale of its action, further studies on the subject are 
certainly in order. Some reasons of this beneficial action 
are self-evident. Where the prostate contains a large 
amount of catarrhal or purulent stagnant secretion, the mere 
mechanical removal of this mass, which diminishes the size 
of the organ, relieving pressure on neighboring organs and 
nerves, is beneficial. Then the massage itself and the re- 



160 GONORRHEA AND ITS COMPLICATIONS 



moval of the secretion improves the circulation in the 
prostate and in the periprostatic veins and lymphatics. It 
tones up its musculature so that new blood reaches its vari- 
ous recesses, and its tissue, as well as its numerous nerve 
plexuses, become better nourished. 

Technique of Massage. The way to perform massage 
properly and effectively is to have the patient, standing with 

his legs well apart, bend over a 
chair or the examining table, 
firmly supporting himself with 
both hands. The index finger of 
the gloved hand, over which an 
extra finger-cot may be put on, 
well anointed with petrolatum 
(for rectal examinations I prefer 
petrolatum to the water soluble 
lubricants), is introduced gently 
into the rectum and the prostate 
is gently but firmly massaged, first 
from the right side toward the 
median line, then from the left 

Special Finger Cot for s id e toward the median line, then 
Massaging the Prostate. 

a few firm, pressing strokes are 

made from above downward. Special pressure is applied to 

any indurations that may be encountered, or to any specially 

soft spots. 

When the massage is completed the patient is told to get 
up gradually and slowly from his stooping position, and is 
given a glass to urinate in. The urine washes away the 
prostatic secretion. 

This is for ordinary cases where there is little discharge, 




CHRONIC PROSTATITIS 161 

and that chiefly catarrhal. But where there is much dis- 
charge and of a purulent character, it is best to have the 
patient urinate first, then fill his bladder with a 2 per cent, 
boric acid solution, then massage him, then tell him to 
urinate, and after he urinates it is well to instill into the 
bladder a dram or two of a 1-1000 solution of silver nitrate, 
instilling a few drops of the same solution throughout the 
urethra. This is to prevent any infection from the prostatic 
secretion. 

Massage in the Horizontal Position. Some physicians 
perform prostatic massage with the patient lying on his 
back, or even on his side. I am opposed to this position, 
because it is much more unsatisfactory than the standing- 
stooping position. The finger can never reach quite as far 
with the patient lying down as with the patient standing up 
and pushing his prostate against the finger. Nor can the 
physician's finger ever get such a leverage with the patient 
in the horizontal position as when the patient is standing. 
For the mere purpose of examination the recumbent posi- 
tion may be sufficient, and when the patient is of an ex- 
tremely nervous temperament, subject to fainting spells, 
that position must sometimes be chosen, but it is never the 
position of choice, and we can never be sure of giving the 
patient a thoroughly satisfactory massage in that position. 
Another point, perhaps not of so much importance, but still 
of some importance, is that when the patient is stooping 
down, the secretion, through gravity, has a tendency to run 
out of the urethra; in the recumbent position it is sure to 
flow back into the bladder. 

Abuse of Prostatic Massage. There is no therapeutic 
procedure, beneficent as it may be, that cannot be abused or 



162 GONOBRHEA AND ITS COMPLICATIONS 



overdone. This is true of massage. Useful as it is, much 
damage may be done by it if it is performed too brutally or 
too frequently. 

There must never be a digging of the finger tips into the 
prostate; there must be only a pressure with the entire 
palmar surface of the finger. Too much force must not be 
used, or the inflammation instead of being allayed may be 
increased in severity, or even necrosis may be caused. Nor 
must the massage be performed too frequently, but here no 
dogmatic statement can be made as to what constitutes fre- 
quency. Some patients can stand massage every other day, 
some only once a week or once in ten days. 

Massage must not be performed when there is acute in- 
flammation in the prostate or an acute exacerbation of a 
chronic inflammation. 

Besides the aggravation 
in the condition of the 
prostate itself that the too 

Finger ) for Massaging frequently or too brutally 

the Prostate o j 

performed massage may 

cause, it may also cause an epididymitis, a seminal 
vesiculitis, and even sciatica. Not too much zeal 
in the best of causes ! 

Instruments for Massage. Instruments, like 
Feleki's finger, used by inexperienced physicians 
or those with very short fingers, for massaging the 
prostate are not to be recommended. They are 
dangerous instruments, as unwittingly too much 
force may be applied in using them. For self- 
massage by the patient, however, they may be rec- 
ommended. There is little danger that the patient 




Instrument ( Feleki's 



CHRONIC PROSTATITIS 163 

may use too much force ; the pain will prevent him. Self- 
massage is performed by the patient while lying on 
his back, undressed. He inserts the instrument, warmed 
and well lubricated with petrolatum, into the rectum and 
moves it up and down, pressing gently on the prostate, for 
a few minutes. This may be repeated three times a week or 
even daily. 

A Few Minor Points. 1. Some patients come to the 
office with full recta, the feces pressing on the prostate. 
This not only makes it unpleasant for the physician, not only 
interferes occasionally with the proper performance of the 
massage, but induces in the patient a desire to defecate. 
Such patients should be told always to empty their bowels 
before coming to the physician's office. If they cannot do 
it spontaneously they should take an enema. 

2. Where the secretion from the prostate is so profuse as 
to run from the urethra, the patient is instructed to support 
himself with one hand only, holding in the other hand a 
small glass under the penis to catch the secretion. 

3. Be on your guard and watch your patient very care- 
fully when giving him the first massage, for some patients 
faint after the first massage. Let the patient get up from 
his stooping position very slowly, make sure that he is not 
pale, and that he has no sensation of fainting. If he com- 
plains of a sense of weakness the best thing is to lay him 
down on the examining table or couch for a few minutes. 

4. In some obstinate cases of prostatitis I have found the 
introduction of a potassium iodide-iodine suppository (see 
No. 2 of the formulas below) followed by a gentle massage 
for 5 to 7 minutes very- beneficial. The massaging ap- 
parently causes a much greater absorption of the K I 



164 GONORRHEA AND ITS COMPLICATIONS 

and iodine than a mere introduction of the suppository. 
Hot Rectal Douches. Another useful measure, but alto- 
gether secondary to massage, is the application of hot water 





Prostatic Psychrophores 

to the rectum by means of one of the numerous prostatic 
psychrophores. This may be done two or three times a 
day for about fifteen to twenty minutes each time. The 



CHRONIC PROSTATITIS 165 

psychrophore is best given into the patient's own hands and 
he is shown how to use it. 

The hot rectal tube applied for about fifteen minutes be- 
fore prostatic massage makes the latter more efficient, per- 
mitting us to express the secretion more readily. Supposi- 
tories of various composition, the formulas for which will 
be found below, also form occasionally a useful aid in the 
treatment. A morphine and belladonna suppository in- 
serted by the patient before he comes to the physician 's office 
is useful in allaying the irritability and making the prostate 
less sensitive, and thus permitting us to manipulate it more 
efficiently than we otherwise could. 

IJ Iodoform!, gr. i Morph. sulph., gr. % 

Morph. sulph., gr. % 01. theobromaa, gr. xxx 

01. theobromae, gr. xxv IJ Bism. iodo-resorcin- 
M.f. supp. No. 1. Tal. sulphonatis, gr. ij 

dos. xij Zinci oxidi, gr. v 

Sig. One t. i. d. 01. theobromae, xxv 

IJ Potassi iodidi, gr. ij IJ Antipyrini, gr. v 
Iodi puri, gr. % Sodii iodidi, gr. iij 

Morph. sulph., gr. % 01. theobromae, gr. xxx 

01. theobromae, gr. xxx IJ Morph. sulph., gr. % 

IJ Ichthyol, gr. ij Ext. belladonnas, gr. % 

Potassii iodidi, gr. iij 01. theobromae, gr. xxx 

Where a psychrophore and the apparatus necessary to run 
a current of hot water are not obtainable, the patient may 
inject into the rectum 6 to 8 ounces of hot water, as hot as 
he can bear it, and retain it for about ten minutes. Instead 
of hot water a saline solution, or a saline solution with 5 
grains of antipyrin and 5 grains of laudanum, is often 



166 GONORRHEA AND ITS COMPLICATIONS 

preferable. It is, however, well to bear in mind that some 
recta cannot bear repeated hot-water injections without 
severe irritation, and they cannot be continued for any 
length of time. The rectal psychrophore, however, can be 
borne without irritation. 

ATONY OF THE PROSTATE AND PROSTATORRHEA 

There is a condition of the prostate which deserves con- 
sideration by itself, under a separate subdivision. It is not 
an inflammation of the prostate and no inflammatory prod- 
ucts are contained in its secretion, but the whole prostate 
seems to be relaxed, atonic, and this condition is best de- 
scribed as atony of the prostate. Its ducts are dilated and 
on mere touching of the prostate with the finger a large 
amount of prostatic secretion oozes out from the urethra. 
The secretion may be quite normal or somewhat catarrhal in 
character. The symptoms of atony of the prostate, how- 
ever, are the same as of the other forms of prostatitis, except 
that the sexual features are more markedly exaggerated. 
Particularly is premature or precipitate ejaculation a prom- 
inent symptom. 

Prostatorrhea is simply a further stage in the development 
of prostatic atony. In prostatic atony the application of 
the finger produces a discharge of secretion, in prostator- 
rhea the prostatic secretion runs out spontaneously or at 
the end of micturition (prostatorrhea mictionis) or after 
defecation (prostatorrhea defecationis) . 

The treatment of atony of the prostate and of prostator- 
rhea is in general the same as of the other forms of prosta- 
titis. Massage plays here the same important role. But 



CHRONIC PROSTATITIS 167 

instead of hot-water irrigations or applications, cold water 
is of more benefit. And it is also in this condition that 
faradization with the prostatic electrode in the rectum and 
the other electrode over the symphysis is very useful. 



CHAPTER XXV 

EPIDIDYMITIS 

Epididymitis is an inflammation of the epididymis. It 
is one of the most frequent, most serious, and at the same 
time most preventable of all the complications of gonorrhea. 
It is in fact a complication that, under proper management, 
should not happen. And if it does happen rather too fre- 
quently in the practice of a physician, we can be quite cer- 
tain that it is the physician who is at fault and not the 
disease. Strong injections, prolonged irrigations, meddling 
with the urethra, passing instruments in the superacute 
stage, overzealous massage of the prostate, are undoubtedly 
causes of epididymitis. When I hear a physician assert, or 
I see one make the statement in print, that epididymitis is 
a complication in thirty per cent. (!) of all cases of gonor- 
rhea, I cannot help thinking that there is something wrong 
with his method of treatment. Of course the patient is 
very frequently at fault; for by walking, lifting, working, 
dancing, drinking, indulging in sexual intercourse, strain- 
ing at stool, using injections forcibly, etc., in short by doing 
things he should carefully avoid, he himself brings about this 
painful complication, which is so dangerous to the perpetua- 
tion of the race. And while we are at this point, we may state 
that it is epididymitis that renders gonorrhea in the male a 
social, a racial disease. Were there no such complication 
as epididymitis, gonorrhea would be nasty, painful, danger- 

168 



EPIDIDYMITIS 169 

ous, but it would be an individual disease. But on account 
of epididymitis, which renders thousands and thousands 
of men sterile, thus endangering the perpetuation of the 
human species, the gonococcus acquires the dignity of a 
racial poison, and gonorrhea that of a racial disease. 

One of the first things the physician has to bear in mind, 
therefore, when treating a case of acute gonorrhea — and 
also chronic for that matter — is to avoid everything and to 
prohibit everything that may be conducive to this com- 
plication. Some cases will occur in spite of the utmost 
care. You cannot forbid the gonococci to penetrate into the 
vas deferens and then into the globus major or minor of 
the epididymis. But these unavoidable cases should not be 
more frequent than two or three in the hundred. In the 
last nine years I have not had a single case of epididymitis 
of my own making, and I have treated plenty of cases of 
acute and chronic urethritis, which goes to show that with 
care and common sense you can avoid many complications. 

SYMPTOMS AND COURSE 

When a man has epididymitis, he knows it. Sometimes 
he knows it several hours before he has the epididymitis, by 
a severe pain in the groin. The pain in the groin is par- 
ticularly severe when the spermatic cord is involved in the 
inflammation. As the swelling of the epididymis proceeds, 
the pain gets more intense and the patient can walk only 
with great difficulty. There is a general feeling of malaise 
(this feeling may precede the actual development of the 
epididymitis by several hours), there is fever, which may 
go up as high as 104° F., and the patient feels undoubtedly 
sick. Sometimes you do not have to tell the patient to go 



170 GONORRHEA AND ITS COMPLICATIONS 

to bed; he is unable to do otherwise. In milder cases the 
patient may be able to walk about, but each step is accom- 
plished with pain, and with a terrible feeling of heaviness 
and dragging down in the scrotum. Quite frequently the 
patient, if of what we call a nervous temperament, shows a 
tendency to faint. Occasionally he feels as if he had been 
hit in the stomach, is nauseated, vomits, and in some cases 
there may be convulsions. 

In acute gonorrhea the onset of an epididymitis generally 
takes place in the second or third week, but it may occur 
as early as the first week or as late as the sixth. When it is 
due to rude instrumentation, to forcible injections, or to the 
patient's carelessness in lifting, dancing, etc., it may take 
place at any time. 

Epididymitis is usually unilateral, but in a large number 
of cases it is bilateral. The swelling of both epididymes, 
however, rarely occurs at the same time; usually one epi- 
didymis swells a few days before the other. It used to be 
thought that epididymitis is more common on the left side. 
This, however, is not so. In my own practice I have seen 
quite as many cases of epididymitis of the right testicle as 
of the left ; and careful researches of other investigators give 
the same conclusion. 

Whether epididymitis occurs by direct extension of the 
inflammation from the posterior urethra or prostate, etc., 
or whether it occurs by microbic invasion, or whether it may 
occur through the lymphatics, is of little importance, and I 
have taken little interest in the discussions pertaining to 
this question. In my opinion it may occur in any of the 
three ways. The principal thing is to know that it occurs 
and to know how to prevent and to cure it. The method 



EPIDIDYMITIS 171 

of its origin does not influence its prophylaxis or treatment. 

A very peculiar phenomenon, which is present in almost 
every case of epididymitis, is the complete cessation of the 
urethral discharge as soon as the epididymis swells. The 
discharge may be ever so profuse, it almost invariably stops 
with the establishment of this complication. Sometimes it 
stops several hours before. When the epididymitis subsides 
or is cured, the discharge starts up again. The rationale of 
this phenomenon has puzzled urologists for many years, and 
is still puzzling us. The most likely explanation is that the 
high temperature (104° F. or 40° C.) either destroys or 
deadens the gonococci. This explanation would leave noth- 
ing to be desired, but for the fact that the cessation of the 
discharge also takes place in cases in which there is a very 
slight elevation of temperature. In its favor is the fact 
that a gonorrheal discharge also often stops in systemic dis- 
eases accompanied by high temperature. 

The usual duration of epididymitis is one to three weeks. 
It is, however, to be borne in mind that a not completely 
cured epididymitis, a nearly cured epididymitis, is very 
liable to relapse; and if a patient begins to work or walk 
about before he is completely cured of the acute attack, or if 
injections and instrumentation are started, a recurrence is 
very likely, and then the epididymitis may last, with greater 
or lesser severity, for two or three months. 

Gonococcal epididymitis very rarely ends in suppuration, 
much more rarely than an epididymitis due to infection with 
other bacteria. But there is one legacy that a gonococcal 
epididymitis leaves much more frequently than other kinds 
do, and that is an induration of the globus major or globus 
minor of the epididymis, with partial or complete occlusion 



172 GONORRHEA AND ITS COMPLICATIONS 

of the lumen of the vas deferens. And if this condition 
occurs in both epididymes, the patient becomes sterile. In 
fact it is very seldom that a gonorrheal epididymitis heals 
so smoothly as to leave absolutely no induration. Very 
often the hardening in either the globus major or the globus 
minor remains with the patient through life, and by feeling 
it we can know absolutely that the patient has had gonor- 
rhea ten or twenty or thirty years before, when there are 
no other symptoms to indicate it. Of patients who suf- 
fered with unilateral epididymitis, about 20 per cent, are 
sterile. Of those who had bilateral, from 40 to 45 per 
cent, remain sterile. This is natural and easy to under- 
stand. 

But there is one phenomenon that requires a little dis- 
cussion: People who have had several attacks of double 
epididymitis are less apt to be sterile than those who had 
one attack. The reason is not difficult to understand. 
When a man has had a double epididymitis just once and 
never had a recurrence, it can be readily assumed that the 
lumina of his vasa deferentia are completely clogged up, so 
that no gonococci can penetrate them; in short, the way is 
completely blocked. People who have recurrent epididy- 
mitis show by this fact alone that their vasa deferentia are 
permeable to a certain extent to noxious agents, and so 
permeable the other way to spermatozoa. It is also quite 
likely that a recurrent attack, in subsiding, causes the reso- 
lution or absorption of some of the inflammatory products 
of the first inflammation, and this causes the previously 
obstructed lumen to become permeable. I have had two 
very instructive cases in brothers, which will be found re- 
ported later on. 



EPIDIDYMITIS 173 

TREATMENT 

The first and most important thing is to put the patient 
to bed. As stated before, in many cases the physician does 
not have to, because the patient is unable either to sit or to 
stand. Even in cases in which the patient is able to walk, 
he ought to be put to bed, for an apparently mild epididy- 
mitis may in a few hours become a very formidable one, 
and it is just the walking and being about that may change 
it from the former into the latter We know that there 
are eases in which it is impossible for the patient to go to 
bed; by doing so he may risk losing his position, his bread 
and butter. There we have to do the best we can, but that 
does not mean that it is right. The patient simply chooses 
what is to him the lesser of two evils, but this choice has not 
the sanction of medical science. It is only too often that 
medical science finds itself opposed by economic conditions, 
and under our present economic system it is the patient's 
economic condition that conquers. But medicine must not 
cease to protest, and it must keep up this protest until such 
time as the dicta of medicine shall be supreme, both in the 
prevention and the cure of disease. 

So, then, the patient is put to bed and the testicles are 
elevated. To accomplish this in the simplest manner, we 
put a broad strip of adhesive plaster across the patient's 
thighs, close under the scrotum, and on this plaster the 
scrotum rests comfortably as on a shelf. The scrotum and 
the thighs are shaved. This makes the removal of the 
plaster easier and less painful, while the removal of the 
hair from the scrotum permits the applications that we 
are to order to penetrate more readily and thus to act more 



174 GONORRHEA AND ITS COMPLICATIONS 

efficiently. The relief, which the patient experiences on 
the testicles being raised, is remarkable. Not only the sense 
of " sickness" and faintness disappears, but every sensation 
of pain is usually gone also. To prevent the scrotum and 
perineum from sticking to the upper edge of the adhesive 
plaster, that portion of the plaster which comes in coatact 
with the scrotum has to be folded over with another piece of 
adhesive plaster, or a gauze pad may rest under the scrotum. 

Instead of the adhesive plaster we may use as a make- 
shift a cigar box wrapped in several thicknesses of flannel 
or toweling. This is put between the patient's thighs and 
the scrotum rests on it. 

Having raised the testicles, the question arises, what ap- 
plication are we going to use, hot or cold ? It is quite true 
that the cold application, and even an ice bag, very fre- 
quently gives the quickest relief. Nevertheless I am not in 
favor of them, because I cannot get rid of the impression 
that induration, with its subsequent sterility, is more com- 
mon in cases in which ice cold applications have been used. 
I therefore prefer frequently changed hot applications. 
My preference is for large gauze compresses wrung out of 
a hot solution of aluminum acetate containing some 
glycerin : 

R Liquoris alumini acetatis, 1 «_„,... 

~. . . y aa 3V111*, 

Glycermi, J 

Aquae, Oj. 

M. ft. mistura. 

The compress is to be covered with oil silk and, if the 
patient must be up and about, the whole put into a well 



EPIDIDYMITIS 175 

fitting suspensory bandage. The compress should be wrung 
out of the hot solution every hour. 

These applications have a decided effect in reducing the 
swelling and moderating the pain, and if continued for sev- 
eral days have, in my opinion, a decided effect in preventing 
any permanent induration in the epididymis. 

The application of compresses is very troublesome, as it 
requires a special nurse, and we therefore must sometimes 
get along altogether without them, or after using them for 
twelve to twenty-four hours we change off to ointments. A 
good ointment properly applied is also very beneficial. My 
favorite formula is : 

ly Unguenti hydrargyri, 3ii , 

Guaiacolis, .1 __ 

Ichthyolis, ... J aa 3j ; 

Unguenti belladonnas, §ss ; 

Adipis benzoati, q. s. ad gii. 

M. Sig. : Apply externally twice or three times a day. 

Very delicate patients are sometimes hypersensitive to 
guaiacol. I have seen it bring on a condition very near 
collapse. Where the patient is very young and delicate, I 
therefore frequently replace the guaiacol with methyl 
salicylate. 

Again, there are cases, where the foregoing ointment 
cannot be prescribed for an apparently trivial, but to the 
patient all important reason : it soils the underwear and the 
bed linen. In such cases the following ointment will be 
found very useful : 



176 GONORRHEA AND ITS COMPLICATIONS 

^ Hydrargyri ammoniati, 3ss ; 

Methylis salicylates, 3j ; 

Morphinae sulphatis, grs. iv ; 

Atropinae sulphatis, gr. j ; 

Adipis lanse, 5 SS > 

Adipis benzoati, gj. 

M. ft, ung. S. Apply externally three times a day. 

The diseased testicle, with its epididymis, is drawn down 
so that the scrotum is tense over it ; the ointment is gently 
but thoroughly rubbed in; some is then spread thickly on 
a layer of cotton, in which the testicle is enveloped, some 
oiled silk is put over it, and the whole is kept in place by 
a few turns of a gauze bandage, or a well fitting suspensory 
bandage may be used. At first this ointment is to be 
changed twice or three times a day, but later a good applica- 
tion of it once in twenty-four hours is sufficient. 

One other useful method of dealing with the testicle may 
be mentioned. That is the injection of colloidal silver (col- 
largol or electrargol, the latter being preferred by Hamonic 
and Asch, as being in a finer state of subdivision) directly 
into the epididymis. I have tried it in a few cases and the 
results seemed favorable. No anesthetic is necessary, but 
one of my patients fell in a dead faint, from which it took 
him two or three minutes to come out. The skin over the 
epididymis is made tense, painted with iodine, and the 
sharp fine needle is plunged directly into the globus major 
or minor, whichever happens to be the most affected part. 
My usual treatment has proved so uniformly successful in 
my hands, however, that I have recourse to this procedure in 
only exceptional cases. 



EPIDIDYMITIS 177 

Internally I order fifteen grains of sodium salicylate four 
times a day, or eight grains of acetyl-salicylic acid three 
times a day. The value of salicylic preparations in epi- 
didymitis is beyond question. They not only reduce the 
fever and the local pain, but also induce a condition of 
euphoria. Where the fever is very high, aspirin may be 
combined with phenacetin or antipyrin. Morphine should 
be guarded against and should be used in very rare and 
extreme cases only, for not only does it keep up the fever 
and lock the secretions but it induces constipation, a condi- 
tion against which we must guard particularly in epi- 
didymitis, because constipation has a decidedly bad effect on 
this complication, and if prostatitis happens to be coexistent, 
it also aggravates that. It is therefore my practice always 
to order some magnesium sulphate in all cases of epi- 
didymitis. It seems to me to exert more than a laxative 
effect, it aids in reducing the inflammation. 

A hot enema is not only good for any existing constipa- 
tion to clear out the rectum, but it does the local condition 
good, that is, it improves any existing prostatitis and 
posterior urethritis, and incidentally also the epididymitis. 
So that a small but hot enema at night, containing perhaps 
fifteen grains of antipyrin and five minims of tincture of 
opium, is a good thing. 

Where the patient is extremely restless and cannot fall 
asleep, chloral or veronal should be given. If morphine is 
ever decided upon, it should be given in the form of rectal 
suppositories, and as a rule % to % grain of morphine will 
be required to produce the desired effect. 



178 GONORRHEA AND ITS COMPLICATIONS 

SHOULD THE URETHRA BE TREATED? 

We come now to the question of the treatment of the 
urethra. Should the urethra be treated during an attack 
of epididymitis ? Locally, absolutely no, under any circum- 
stances. This was a universally accepted dictum for many 
years, but recently some ultra-active urologists have thought 
that they didn't see any reason why the urethra should not 
be treated, if the injections, irrigations, etc., are only given 
gently and carefully. Let those urologists settle the matter 
with their own consciences. I repeat that under no circum- 
stances whatever should the urethra be treated locally dur- 
ing an attack of epididymitis. There is no injection or 
irrigation so gentle that it may not aggravate matters, cause 
a relapse, or turn the declining stage of the epididymitis 
into a furiously acute stage. To treat the urethra with any 
injection, irrigation, or instrument during an acute epi- 
didymitis is criminal folly, but internally we may keep on 
giving the same medicines, demulcents, hexamethylena- 
mine, sandalwood oil, or preparations containing it, etc., 
though even these are best given in smaller doses than when 
no epididymitis is present. 

Where the patient cannot go to bed, then we start at once 
with the application of the ointment above described; oint- 
ment, big layer of nonabsorbent cotton, oiled silk, the whole 
supported by a well fitting suspensory or jockstrap. A 
home-made T bandage from a waistband and a towel, while 
not elegant, answers the purpose and is much cheaper, which 
to the poor is an item. As it is, gonorrhea is a very ex- 
pensive luxury, which only the rich and very well-to-do 
may permit themselves. 



EPIDIDYMITIS 179 



STRAPPING THE TESTICLE 



Strapping the testicle is a very beneficial measure. It 
not only relieves the pain, but it helps in the absorption of 
the inflammatory exudate, and if properly applied the swell- 
ing diminishes rapidly under its influence. In six to eight 
hours the diminution in the size of the swollen epididymis 
may be so great as to be clearly apparent. The strapping 
with overlapping strips of adhesive plaster, as originally 
introduced by Friecke, was very popular for a long time, 
and if properly applied it did its work well; but it was 
troublesome, its removal every day (because the testicle 
having diminished in size it was no longer useful) caused 
the patient a great deal of pain, and if applied improperly, 
it was apt to do more harm than good. It is, therefore, now 
used by very few genitourinary surgeons. In this country, 
at least, it has been to a great extent superseded by the 
rubber bandage suggested by Chetwood. A piece of light 
rubber bandage, about two inches wide and three to four 
inches long, is taken, and a small piece of adhesive plaster, 
one half an inch wide and two inches long, is attached to 
one of its ends. The diseased testicle is pushed down to 
the scrotum until the skin is made as tense as possible over 
it ; the rubber bandage is wrapped around the testicle, and 
is held in place by the strip of adhesive plaster. It may 
be changed daily, which is easily done ; it is simply a matter 
of a minute. Care must be taken, however, that the strip 
of adhesive plaster is attached above the largest circumfer- 
ence of the testicle. If it is attached under it, the testicle 
will naturally slip out and up. 

The epididymis may swell to the size of a fist or even 



180 GONORRHEA AND ITS COMPLICATIONS 

larger, in fact the size in exceptional cases is hardly be- 
lievable. While on superficial examination it seems that it 
is the testicle that is swollen, still by careful manipulation, 
when the scrotum is raised and the patient is in bed, we can 
find that the testicle is intact, of the normal size, and merely 
semi-surrounded by the enlarged and inflamed epididymis. 
Occasionally, however, there is an effusion of fluid into the 
tunica vaginalis, and the testicle itself may participate in 
the inflammation. "We then have to deal not with an epi- 
didymitis but with an orchiepididymitis or epididymoor- 
chitis. 

SEQUELS OF EPIDIDYMITIS 

The induration of the epididymis and the occlusion of 
the lumen of the vas deferens have for their result, as stated 
before, sterility of the male. They either permit absolutely 
no spermatozoa to pass, the condition being one of aspermia, 
as much so as if the patient had been castrated; or the 
spermatozoa that pass are very few in number and deformed, 
and do not possess enough vitality to impregnate the ovum. 
But, strange as it may seem, this sterility is not accompanied 
by any impotence or diminished libido. The latter may 
even be increased. Nor does the patient's general health 
seem to be in any way influenced for the worse. I say this 
is a strange phenomenon, because we know of no other gland 
in the human organism whose excretory duct can be com- 
pletely obliterated without any damage to the system. We 
can only assume that in some manner some of the products 
of the testicular function are absorbed into the general cir- 
culation, even though the ducts which give exit to the 
spermatozoa are obliterated. 



EPIDIDYMITIS 181 

Beside the induration of the epididymis, with the eon- 
sequent sterility, to which epididymitis is apt to give rise, 
its only other sequel is a neuralgic pain in the testicles, 
which may be very difficult to get rid of. This pain is apt 
to make itself particularly noticeable in run down sexual 
neurasthenics. 

A tendency to tuberculosis of the testicle is also mentioned 
as one of the sequelse of epididymitis. Personally I have 
not noticed any such tendency, although a priori it is not 
difficult to understand that in a patient predisposed to tuber- 
culosis, tuberculosis of the epididymis and the testicle may 
develop after those organs have been subjected to a severe 
inflammation. 

OPERATIVE TREATMENT OF EPIDIDYMITIS 

Of late years considerable has been written concerning the 
treatment of epididymitis by puncture and epididymotomy. 
I am not enthusiastic about the operative treatment of epi- 
didymitis. It will always remain almost exclusively a hos- 
pital procedure. It requires general anesthesia and the 
patient must stay in bed a week or two — so where is the 
gain ? Suppose the patient xioes recover a few days earlier 
than he does by nonoperative treatment; the dangers of 
general anesthesia, the postoperative vomiting, the fear of 
the operation, are not worth the difference. And, besides, 
I do not believe in operating in any condition where 
we can get along without an operation, and I have 
not seen a single case of epididymitis which needed an 
operation. If properly treated from the start the patient 
is well in a week or two, and only in rare cases in three 
weeks, and without the shock and the expense of an opera- 



182 GONORRHEA AND ITS COMPLICATIONS 

tion. I repeat, therefore, that epididymotomy will most 
probably always remain a hospital operation — particularly 
recommended for soldiers and sailors, whose time is so * - val- 
uable" to the country. It will not become the method of 
choice in general practice. 

CASE REPORT 

The following two cases present some points of in- 
terest. A and B are brothers. A was a "rounder," had 
several attacks, and with practically every attack he de- 
veloped an epididymitis ; sometimes on the right side, some- 
times on the other and sometimes on both. He had some 
attacks of epididymitis without an accompanying gonorrhea. 
In five years he had nine attacks of epididymitis, for the 
last five of which he was under my treatment. He then 
married, and at the end of eleven months his wife gave 
birth to a healthy child. A year later she had another 
baby. 

B, the younger brother, had an attack of bilateral epi- 
didymitis, which laid him up for six weeks. Three or four 
months later he married, and though he has been married 
for three years and is very anxious to have a child, his wife 
is still childless. She has been examined and nothing seems 
to be wrong on. her part, but no spermatozoa can be found 
in B's semen, obtained either by stripping the seminal 
vesicles or in the natural way in a condom. 

These cases seem to corroborate the observation made by 
a number of physicians that the patient who had one attack 
of bilateral epididymitis is more apt to be sterile than he 
who had several. 



CHAPTER XXVI 
SEMINAL VESICULITIS 

Seminal vesiculitis or spermatocystitis is an inflammation 
of the seminal vesicles, either one or both. It is impossible 
to say how frequent this complication of gonorrhea is, be- 
cause if present in a mild degree it may give practically no 
symptoms, and even if present in a fairly severe degree 
its subjective symptoms are confounded with or overshad- 
owed by those of the posterior urethra and the prostate. It 
is only by a careful rectal examination that we become aware 
of its presence. 

The most common cause, and by far the most important 
cause, of seminal vesiculitis is gonorrhea. An important 
predisposing cause is coitus during the acute or subacute 
stage of gonorrhea. 

The symptoms, as stated, may not be distinguishable from 
those produced by the onset of an acute prostatitis. There 
is one symptom, however, which distinguishes it from the 
latter, that is the ejaculations may be precipitate and the 
semen may be mixed either with blood (hemaspermia) or 
with pus (pyospermia). When the onset is very acute the 
patient may feel nauseated, may vomit and feel like faint- 
ing. 

The diagnosis of a seminal vesiculitis is made : (1) by rectal 

examination; (2) by examination of the secretion obtained 

by expressing or "stripping" the seminal vesicles. The ex- 

183 



184 GONORRHEA AND ITS COMPLICATIONS 

animation by rectum is performed the same way as the ex- 
amination for prostatitis, only here the patient must in- 
variably assume a strongly stooping position, bending his 
body practically to an angle of 90 degrees. The finger must 
be pushed in as deeply as possible, for the seminal vesicles 
lie above the prostate and are directed outward. Sometimes 
the vesicles are situated so high that even the most expert 
finger cannot reach or feel them. Normal vesicles, par- 
ticularly when empty (soon after coitus) can hardly be per- 
ceived by the examining finger and when felt give the pa- 
tient no pain, but when inflamed and distended with secre- 
tion they may be felt like two miniature, tortuous "frank- 
furter" sausages on each side of the prostate, and pressing 
on them causes the patient the most exquisite, the most 
sickening pain imaginable. Strong pressure on an inflamed 
seminal vesicle is even more apt to induce syncope in the 
patient than is the massaging of an acute prostate. There 
is one difference that I have noticed between the sensation 
produced by massaging a seminal vesicle and a prostate: 
the patient gets used to the handling of the latter, but 
never gets used to the handling of the former, he always has 
a sickish feeling after it. 

To examine the vesicular secretion properly, so as to be 
sure that it comes from the vesicles and not the prostate, 
the prostate is first massaged thoroughly, then the patient 
urinates, the bladder is washed out with a quart of boric 
acid (2 per cent.) or mercury oxy cyanide solution (1-5000), 
then the bladder is filled again with warm boric acid solu- 
tion, the vesicles are massaged, and the patient empties his 
bladder. These washings contain the vesicular secretion, 



SEMINAL VESICULITIS 185 

which is then examined microscopically. Microscopic ex- 
amination will show numerous blood and pus cells, deformed 
spermatozoa, gonococci, and various other bacteria. 

The greatest gentleness must be used in massaging the 
seminal vesicles. They are very tender organs, their walls 
are thin, and serious damage may be produced by handling 
them roughly. The suggestion, therefore, to use a prostatic 
instrument like "Feleki's Finger" for massaging the ves- 
icles when the finger is too short to reach them must be con- 
demned unequivocally. "We can never know just what force 
is being applied when we use a heavy steel instrument like 
this. There is great danger of rupturing the delicate wall 
of the vesicle. 

I have already mentioned that in some patients the vesi- 
cles are situated so high or so out of the way that the most 
expert finger cannot reach them and therefore cannot mas- 
sage them, but there are cases where we can feel the vesicles 
very well and still by the most persistent massage are un- 
able to express any of their secretion. This may be due 
either to the peculiar situation of the ejaculatory ducts or 
to their complete inflammatory occlusion. Massaging of 
such vesicles will of course do no good, and if the symptoms 
which their inflammation produces are severe and do not 
yield to treatment they will have to be dealt with, surgically. 
The surgical operation consists in draining the vesicles 
through the vas deferens, as suggested by Belfield of Chi- 
cago, or in vesiculotomy, as suggested by Fuller of New 
York ; but as these are not operations, for the general prac- 
titioner we will not use up space in describing them here. 

The treatment of seminal vesiculitis is essentially the 



186 GONORRHEA AND ITS COMPLICATIONS 

same as that of prostatitis : gentle massage, hot rectal irriga- 
tions, the thermophore, hot sitz baths, and gonococcal or 
preferably mixed vaccines. 

Vesiculitis is the longest lasting of all the complications 
of gonorrhea. Annoying as prostatitis is, a seminal ves- 
iculitis is still more so. It requires indeed an inexhaustible 
fountain of patience on the part of both physician and 
patient. Nevertheless it must be treated, because inflamed 
and purulent seminal vesiculitis form the chief source 
whence arise the various metastases of gonorrhea, such as 
gonorrheal rheumatism, gonorrheal myelitis, gonorrheal in- 
flammation of the serous membranes, endocarditis, and 
gonococcemia. 



CHAPTER XXVII 

GONORRHEAL PROCTITIS-— GONORRHEA 
OF THE RECTUM 

Gonorrhea of the rectum is not an uncommon occurrence. 
And unfortunately it is rather on the increase. One sees 
more cases of gonorrhea of the rectum now than one used 
to see, say, twenty years ago. It is much more common in 
women than in men, the infection being carried from the 
vagina to the anus. The infection is particularly easily 
transferred in women who have given birth to children and 
who have a lacerated perineum. 

The diagnosis can be readily made from the history of 
the case, from finding gonorrhea in the genital tract, from 
the pain and strain in the rectum, and from the mucopurulent 
and occasionally sanguinolent discharge. Some cases are so 
mild that it is difficult to differentiate between them and 
simply catarrhal proctitis, but the finding of the gonococcus 
in the discharge settles the diagnosis. 

As a rule gonorrhea of the rectum is readily amenable to 
treatment, and is cured without leaving any sequelae. In 
some cases, however, severe erosions of the rectal mucous 
membrane are produced, which on healing contract and give 
rise to stricture of the rectum. 

The treatment is simple. The rectum is examined by aid 
of a speculum and a strong light or by the proctoscope. 

Erosions are touched with strong solutions of silver nitrate, 

187 



188 GONORRHEA AND ITS COMPLICATIONS 

and injections of silver nitrate or protargol into the rectum 
are given three or four times a day. The strength of the 
silver nitrate solution may be from 1-1000 to 1-500, of the 
protargol solution 1-200 to 1-100. From 4 to 8 oz. is used 
per injection, and each injection is held in ten minutes. 
Besides the injections I prescribe protargol suppositories, 
each suppository containing 1 to 2 grs. of protargol. 
These may be used twice or three times a day. 

5 Protargol gr. i 

01. Theobromatis gr. xx 

Mf. Suppos. No. 1. Tal. Dos. No. xxx 

Sig. one t. i. d. 

IJ Argyrol gr. v 

Ol. Theobromatis gr. xxv 

Mf. Suppos. No. 1. Tal. Dos. No. xxx 

Sig. one t. i. d. 

Constipation and straining at stool must of course be care- 
fully guarded against. Before giving the injections a plain 
injection of water or saline solution is given, so as to make 
sure that the rectal mucous membrane is clean and free from 
fecal matter. The itching around the anus is sometimes 
very severe in gonorrheal proctitis, but this is readily 
remedied by frequent washing of the anus with hot water 
and subsequent painting with a 10 per cent, solution of 
silver nitrate. 



CHAPTER XXVIII 

GONORRHEAL STOMATITIS— GONORRHEA 

OF THE MOUTH 

The existence of genuine cases of gonorrheal infection of 
the mouth is no longer a subject of discussion. Taking in 
consideration the fact that the mouth is lined with the same 
variety of epithelium as is the urethra, and taking in con- 
sideration the further fact that certain sexual perversions 
are quite common, the surprise is not that gonorrheal in- 
fection of the mouth exists but that the cases are relatively 
so few in number. 

On the whole, the buccal mucous membrane is very re- 
sistant to the gonococcus. In his entire practice the writer 
has had but three cases of gonorrheal stomatitis where there 
could be no question as to the diagnosis — two in women and 
one in a man. 

The cause of the infection is a purely local one, that is, it 
is due to the direct transference of the gonococcus into the 
mouth. I do not share the view that there is such a thing 
as a systemic gonorrheal stomatitis, that is a stomatitis 
caused by the gonococcus or its toxins affecting the mouth 
through the blood. The method of infection in adults is 
due to pervert practices, or it may perhaps in some cases be 
due to transferring the gonococcal pus with the fingers. In 
the newborn it is due to infection from the mother as the 
child passes through the vaginal canal. 

189 



190 GONORRHEA AND ITS COMPLICATIONS 

The symptoms of gonorrheal stomatitis are : a raw feeling 
in the mouth with an extremely nasty taste ; the tongue may 
become considerably swollen; the mouth may be hard to 
open ; the gums may swell, though not necessarily so. The 
expectoration is thick, ropy, occasionally bloody ; sometimes 
it is slight in amount, in other cases it may be very abundant. 
In some cases swallowing is very painful, and in some cases 
impossible. The sub-lingual, parotid and lymphatic 
glands usually swell; there is no record, however, of these 
glands going on to suppuration. 

Properly treated this horribly nasty infection is cured in 
one to three weeks. The treatment is simple : touching with 
the silver nitrate stick or with a saturated solution of silver 
nitrate any eroded spots, and using a solution of silver 
nitrate 1-5000 as a gargle, which is to be repeated every 
hour. Instead of silver nitrate we may use 1-1000 protargol 
solution as a gargle. The solution of either the nitrate of 
silver or the protargol should be kept from three to five 
minutes each time in the mouth, and the gargling should 
be done thoroughly, so as to reach the fauces. Where 
gargling is difficult the solution of silver nitrate 1-1000 or 
protargol 1-200, or argyrol 5 per cent., should be used on a 
cotton swab, the throat, tongue, gums, inside of cheeks, etc., 
being thoroughly swabbed four or five times a day. 

Gonorrhea of the Nose. It is questionable whether 
gonorrhea of the nose exists. Certainly not a single au- 
thenticated case has been reported. The subject may there- 
fore be dismissed with this brief paragraph. 



CHAPTER XXIX 
STRICTURE 

Stricture is a narrowing or constriction of the caliber of 
the urethral canal at some point or points. As the urethra 
is ordinarily a closed canal, dilating only for the passage 
of urine, semen and instruments, it would be more correct 
to define stricture as a loss of or diminished dilatability of 
the canal. 

Strictures are generally divided into spasmodic, inflam- 
matory and organic. It is only to the latter kind that the 
name stricture should be applied. A spasmodic stricture is 
really but a spasm of the compressor urethras muscle, and 
should be referred to as a spasm of the muscle or spasmodic 
constriction. Inflammation itself rarely if ever produces a 
definite constriction of the urethral lumen, definite enough 
for instance to cause retention of urine. An inflammation 
superadded to a previous organic stricture may cause com- 
plete retention, but then it is wrong to refer to it as an 
inflammatory stricture. It is merely an organic stricture 
which has become inflamed. The entirely different methods 
of treatment in spasmodic and organic strictures will show 
that spasmodic stricture does not deserve the name of stric- 
ture. As spasmodic stricture is of little importance path- 
ologically, I will devote but little space to it, paying special 
attention to organic stricture, and particularly to organic 

stricture of gonorrheal origin. 

191 



192 GONORRHEA AND ITS COMPLICATIONS 

Strictures are not met with nowadays with the same fre- 
quency that they used to be in former days. This is both 
because there is less neglect on the part of patients in treat- 
ing themselves for gonorrheal affections, and because our 
treatment is more rational and more scientific than it used 
to be. But even so they occur with greater frequency than 
they should, and a stricture occurring in a patient who has 
been under a physician's treatment right along is a direct 
reproach to the physician. It shows that the treatment was 
either insufficient or incorrect, for while we cannot prevent 
epididymitis in every one of our gonorrheal patients, while 
we cannot prevent prostatitis in every one of our cases, 
stricture can be and should be prevented in every case. 
We cannot prevent the migration of the gonococci into 
various glands and neighboring organs, once they invaded 
the submucous tissue of the urethral canal, but we can pre- 
vent connective tissue formation in every instance. 

Organic stricture is a narrowing of the urethra formed 
by bands of connective tissue in the mucous and submucous 
layers of the canal. It may be due to trauma (wound, 
injury), and such strictures are called traumatic, or to 
inflammation of the urethra. Of these inflammations the 
most common one is gonorrhea. While a stricture may be 
produced by a non-gonorrheal urethritis, still it is so rare 
as to be practically negligible. In fact all possible causes 
of stricture pale into insignificance as compared with the 
one great cause, namely gonorrhea, which is the etiologic 
factor in about 80 or 85 per cent, of all strictures. 

A stricture that permits the passage of a 22 French 
bougie or sound is referred to as stricture of wide caliber. 
Those that are so narrow that they will not permit the 



STRICTURE 193 

passing of a 22 or 20 French, sound are spoken of as stric- 
tures of a narrow caliber. A stricture that will permit the 
passage of only a filiform bougie is spoken of as filiform 
stricture. A stricture that does not permit the passage even 
of a filiform is spoken of as an impermeable stricture, and 
causes complete retention of urine. Strictures which are 
dilatable by sounds but immediately return to their former 
caliber are referred to as resilient strictures. 

Strictures may be single, but this is rarely the case ex- 
cept when they are of traumatic origin. When of gonor- 
rheal origin they are generally multiple. "We generally 
find two or three strictures in the same urethra; in excep- 
tional cases we may find as many as 15 or 20. Narrow 
strictures (imagine a thread tied around the urethra) are 
spoken of as linear; broader strictures (imagine a tape tied 
around the urethra) are referred to as annular, ring-like. 
Multiple strictures, or broad annular strictures in which 
the lumen instead of being in the center is in the side of the 
constriction and in which the entire passage becomes tor- 
tuous, are spoken of as tortuous strictures. Strictures with 
which the general practitioner has to deal are fortunately 
most commonly in the anterior urethra. Traumatic stric- 
tures are generally situated in the membranous urethra. 
There are no strictures, or so seldom as to be entirely neg- 
ligible, in the prostatic urethra. 

symptoms 

A stricture of wide caliber, or even of a somewhat narrow 
caliber, may present, no symptoms that the patient is aware 
of. A patient may have a stricture for ten or more years 
without knowing it, or without paying any attention to it, 



194 GONORRHEA AND ITS COMPLICATIONS 

when suddenly, after a debauch, or sexual excess, or a cold, 
he is taken with complete retention of urine, when he ap- 
plies to the physician, who then discovers a stricture of 
apparently many years' standing. 

But as a rule strictures do give symptoms. One of the 
commonest ones is the well known gleet, which consists of 
a slight urethral discharge. The discharge is generally 
supposed to be most common in the morning, but this is 
only so because during the night the patient passes the 
longest time without urinating, and the discharge has time 
to accumulate in sufficient amount to be noticed. But if 
the patient should abstain from urinating during the day 
for eight or nine hours we will be sure to find the discharge 
then too. In fact I have had a number of cases in whom 
the discharge in the morning was extremely scanty, so as 
to be noticed or squeezed out only with difficulty, while 
towards evening after their day's work it was much more 
abundant. This was also true of shreds in the urine. 
While as a rule the shreds are much more numerous in the 
morning, this is only because of the longer time passed with- 
out urinating. And just as the discharge may be more 
abundant in the evening, so the morning urine may be prac- 
tically free from shreds while the evening urine, if the pa- 
tient abstained from urinating for several hours, may be full 
of them. While a gleet may occur without a stricture, still 
stricture is its most common cause, and in every case of 
obstinate gleet, refusing to heal under ordinary injections, 
we should suspect stricture; and on examination we will 
in the vast majority of cases find it. 

The next symptom is a change in the size and character 
of the urinary stream. It is this that often brings the 



STRICTURE 195 

patient to the doctor. Besides being smaller in size than 
usual, it may assume a fantastic direction, going either to 
one side or downward, or may become corkscrew shaped; 
or, which is very common, it splits in two or three different 
directions. 

Then there is almost invariably dribbling of the urine. 
The final contraction of the vesico-urethral musculature is 
insufficient to drive out the last drops of the urine on 
account of the obstruction met on the way, and they there- 
fore dribble away by the action of gravity. Very often 
they do not dribble away entirely but remain, some in front, 
some in back of the stricture, keeping up a low grade of 
inflammation. Having to overcome an obstacle during each 
act of urination, the musculature of the neck of the bladder 
becomes hypertrophied, and as is the case with all unnat- 
urally hypertrophied muscle, it becomes weakened. There 
is developed a low-grade inflammation of the neck of the 
bladder with some cystitis, and this increases the frequency 
of micturition, which is another important symptom of 
long-standing stricture. The patient may have to urinate 
every hour or every half hour during the day and several 
times during the night. The pain is sometimes slight but 
may become excruciating, so that the patient will double up 
during the act of micturition. 

In long neglected stricture there may be hypertrophy of 
the bladder walls, well developed cystitis, pyelonephrosis, 
pyelitis, etc., but these are remote effects of stricture, and 
we are here concerned only with gonorrhea and its imme- 
diate complications. 

And finally we may have complete retention with ex- 
travasation or infiltration of the urine and various fistulae. 



196 GONORRHEA AND ITS COMPLICATIONS 

The sexual symptoms of stricture are important, because 
they are frequent, annoying, and often overshadow the 
urinary symptoms caused by the stricture. These symp- 
toms are weakened or imperfect erections, premature ejac- 
ulation, diminished voluptas during the act, a feeling of 
scalding or burning in the urethral canal during and after 
the ejaculation of the semen, and occasionally a disturbance 
in ejaculation. The semen may fail to discharge externally 
at all, running back into the bladder, or it oozes out slowly 
after the erection has subsided. As a rule there is a dimin- 
ished desire for intercourse but occasionally, as so often 
happens in the inflammations around the posterior urethra 
and the prostate, there may be just enough inflammation to 
keep up an irritation which makes the patient believe that 
he is constantly erotically excited; it is a fictitious libido. 
In irritable stricture pollutions are also frequent, and it is 
quite frequently here that we have to deal with retro- 
pollutions or ejaculation of the semen into the bladder. 

TREATMENT 

The treatment of stricture is mechanical and operative. 
The general practitioner will seldom have to have recourse 
to the operative method, as we can accomplish as good re- 
sults with the vast majority of strictures by mechanical 
dilating. 

Dilatation is performed by means of silk woven bougies, 
steel sounds, and the various several-branched dilators. 
For strictures which will not admit any more than 12 or 15 
French we use silk-woven bougies, because a very thin steel 
sound is apt to make a false passage. But for strictures 
above 15 we use steel sounds or dilators. 



STRICTUEE 197 

The greatest gentleness must be exercised in introducing 
a sound. Very much damage, aggravation of the inflamma- 
tion, chills, septic infection, false passages, severe hemor- 
rhages, have been caused and are being caused by physicians 
with too heavy a hand or too much in a hurry to accom- 
plish results. 

To introduce a sound properly wash the glans and the 
meatus well with a 1-5000 bichloride solution, irrigate the 
portion anterior to the stricture with a 2 per cent, boric acid 
solution, and if you see the patient for the first time, or if 
you know that the patient is of a nervous disposition, instill 
a few drops of a 4 per cent, alypin and a few drops of a 
1-1000 adrenalin solution in the neighborhood of the stric- 
ture. This not only takes away the pain to a great extent, 
but also makes the lumen of the stricture larger, more 
patent, by taking away the inflammatory swelling. Then 
lubricate the bougie, or if it is a sound pass it first through 
a flame, which sterilizes and warms it at the same time, 
then lubricate it with a sterile lubricant, oil being the best, 
and introduce it gently through the stricture. Do not try 
to force it too much. Slight force is permissible, but not 
enough force to tear or divulse the stricture. Sometimes by 
waiting with the tip of the sound at the opening of the 
stricture for a few moments, a stricture which seemed to be 
absolutely impermeable will become permeable and permit 
the passing of the sound. This is true not only of spas- 
modic but of genuine organic strictures, because a slight 
amount of dilatability most of them possess. 

After having introduced the sound let it stay there for 
five to ten minutes. I believe that passing the sound and 
taking it right out is insufficient. It is not only the mo- 



198 GONORRHEA AND ITS COMPLICATIONS 

mentary dilatation of the stricture that does good, but the 
more or less prolonged contact of the stricture with the steel 
sound that produces the absorption of the scar tissue. 

Always be sure to have the patient take 10 grains of 
hexamethylenamine about an hour before he comes to the 
office, and 10 grains afterwards. Many infections and 
urethral chills are avoided thereby. 

The sounds may be introduced every two or three days, 
and at each visit we may use a larger size sound. It will be 
found that very often when we are unable to pass a larger 
sized sound we will be able to do so if we pass before a 
smaller sized sound: In other words, suppose we pass on 
Monday a 24 size sound ; if we try on Wednesday to pass a 
25 or 26 size sound we may not be able to do so, but if we 
pass again a 24 size sound, leave it in for a moment, then 
remove it and try to pass a 25 or 26 size sound, the latter 
will pass in easily. In this way we continue the passing of 
the sounds until we are able to pass easily a 30 or 32. 
Higher we need not go. When we have reached that size 
we can order the patient to come every two weeks or every 
month for an examination to observe if the stricture began 
to recontract, and it is also a very good idea to teach the 
patient himself to pass the sound. If he is intelligent and 
can be taught to use asepsis and commonsense, we can trust 
him to pass the sound once a month or once in two months, 
and in this way there is no danger of his stricture recontract- 
ing. 

DILATORS 

The dilators introduced by Kollmann and Oberlander 
present a great advantage over the steel sounds, for they 
may be passed through a meatus as small as 21, and can 



STRICTURE 199 

be dilated when in the urethra to any size we wish. As 
most of the strictures that the general practitioner has to 
deal with are in the anterior urethra, it is the anterior or 
straight dilator that he will have to use mostly. The thin 
rubber sheath which accompanies the dilators is slipped on 
the dilator, the dilator is stretched to its full capacity to 
make sure of the integrity of the sheath, it is then closed 
again, lubricated with a sterile lubricant, introduced into 
the urethra, and dilated to the desired size. The in- 
dicator dial on the dilator shows just the degree of dilata- 
tion, and with each sitting the dilator may be dilated two 
or three divisions higher. 

After the removal of the sound or the dilator it is well 
to instill a few drops of a % of 1 per cent. (1 :500) solution 
of tincture of iodine in the neighborhood of the stricture, 
which acts both as an antiseptic and as a ''healing" agent. 

MEATOTOMY 

Some meati are so small that they won't even permit the 
passage of a dilator. Such meati must be cut before we can 
expect to do anything with the stricture. While there are 
numerous meatotomes on the market invented by surgeons 
anxious to be immortalized by giving their name to an in- 
strument or by enterprising manufacturers, they are all 
superfluous. All that is necessary is a blunt-pointed 
bistoury. 

"Wash the glans and the meatus thoroughly with a 1-5000 
bichloride solution. If you are very particular, irrigate the 
anterior urethra for a couple of inches or swab it out with 
a cotton swab dipped in the same solution, then insert in 
the meatus a bit of cotton dipped in a cocaine or alypin- 



200 GONORRHEA AND ITS COMPLICATIONS 

adrenalin solution. Or instead of the cotton just a half 
grain of cocaine powder or crystals may be deposited on the 
floor of the meatus and about 5 drops of adrenalin 1-1000 
dropped; in. After about three minutes the floor of the 
meatus will be seen to have become blanched. You then in- 
troduce the bistoury and cut exactly in the median line on 
the floor of the urethra as far as you wish to have it cut. 
Supporting the floor of the meatus with one finger of the 
left hand will tell you just exactly whether and how far to 




Cauterizing Tip for Meatotomy 




Meatus Sound for Dilating and Measuring 
the Meatus. 

cut. After cutting pass a short anterior sound to make 
sure that you have cut sufficiently. It is better to cut a 
little more than a little less, because there will be some re- 
contraction on healing. If cut exactly in the median 
line there will be very little bleeding. If there is an abun- 
dant hemorrhage compress the urethra laterally for several 
minutes, or put a bandage around the glans, and the hemor- 
rhage will stop. Before sending the patient home take a 
piece of a wooden applicator or a toothpick, wrap some ab- 
sorbent cotton well around it, dip it in 1-1000 adrenalin 
solution, and insert it in the meatus. The patient removes 
it at the next urination. 

Never cut on the roof of the urethra, as I have seen more 
than one physician do. It only cuts the glans without act- 



STRICTUEE 201 

ually dividing the constriction, which is on the floor of the 
urethra. 

Some meati have a tendency to reunite unless prevented 
from doing so, and this is prevented by passing a short steel 
sound several times a day, and by inserting between urina- 
tions a bit of cotton smeared with borated vaseline. 

When the little operation of meatotomy is healed or about 
healed, then we commence with the introduction of sounds 
or dilators. 

While the meatus should be cut sufficiently large to admit 
24 or 26 French, I see no reason for cutting it as some do to 
32 or 34. There was an excuse for doing it before the intro- 
duction of dilators. It was necessary in order to permit us 
to pass a 32 or 34 sound. But now when we have the 
dilators with a caliber of 21-23 French it is not necessary 
to cut the meatus much more than that. The excuse that 
the physician does not possess a Kollmann dilator and has 
only sounds is not a valid one. He should purchase one. 
The patient's urethra must not be slashed merely because 
the physician does not possess a necessary instrument. 

I am opposed to excessive meatotomies not on purely 
sentimental or esthetic grounds, but because in my opinion 
they interfere with proper urination, and quite possibly 
also with proper intercourse. When water issues from a 
tube of a narrow caliber, but with a wide opening, it will 
splash, and people with excessively cut meati do not pass a 
uniform strong stream of urine. I have had the impression 
that excessively cut meati are also a cause of premature 
ejaculation. I am therefore opposed to cutting the meatus to 
a size larger than 24 or 26. With the dilators it is unneces- 
sary, and it may be injurious, 



CHAPTER XXX 
GONORRHEAL ARTHRITIS 

Gonorrheal arthritis or gonorrheal inflammation of the 
joints is not a very frequent complication of gonorrhea. It 
occurs in about 2 per cent, of all gonorrheies and is much 
more frequent in the male than in the female sex, not only 
absolutely — for this is self-understood, so many more men 
have gonorrhea than women — but also relatively. 

But he whom it does attack has the devil to pay. While 
of late the results of our treatment have been better than 
they used to be, nevertheless there are still cases which resist 
every kind of treatment, and I know personally several 
cases of patients whose careers have been ruined by this 
complication. One is the case of a young pianist, very 
talented and very promising, who had to give up his hopes 
and his profession on account of an ankylosed wrist joint, 
due to gonorrheal arthritis. Another case is that of a fairly 
well known surgeon whose finger joints became thickened 
and somewhat ankylosed, and who had to give up surgery 
and fall back on internal medicine, where he is much less 
of a success than he would have been in surgery. 

At first no causal relationship was thought of between 
joint inflammations and gonorrhea. When a patient hav- 
ing gonorrhea developed inflammation of one or more joints 
it was considered merely a coincidence. Any man can get 
rheumatism, and an inflamed joint during the course of an 

acute or chronic gonorrhea was merely considered rheu- 

202 



GONORRHEAL ARTHRITIS 203 

matism, for which the gonorrhea was not in any way re- 
sponsible. Later on when cases of arthritis in the course 
of gonorrhea were seen to be too frequent to be accounted 
for merely by coincidence it was thought that the gonorrhea 
acted as a predisposing cause by weakening the organism, 
reducing resistance, etc. Finally, however, gonococci were 
found in the exudation around the joints, and it was then 
seen that the gonococcus plays not merely a predisposing but 
a direct role. 

It must not be thought, however, that in every case of 
gonorrheal arthritis gonococci may be found. In some 
cases other bacteria, such as staphylococci and streptococci 
are found ; in still others no bacteria whatever can be found. 
In such cases it is assumed that the inflammation is caused 
not by the gonococci themselves but by the toxins generated 
by the gonococci. 

Nor must we blindly assume that every inflammation of 
a joint occurring during the course of a gonorrhea must 
necessarily be gonorrheal, for a patient with gonorrhea may, 
the same as any other man, get an attack of acute inflam- 
matory rheumatism. This must be borne in mind to avoid 
regrettable failures in practice. 

While any gonorrheal focus in the genito-urinary tract 
may give rise to gonorrheal arthritis, it is particularly fre- 
quent in cases of prostatitis and seminal vesiculitis. The 
latter is considered the most important etiologic factor on 
account of the rich network of bloodvessels which surround 
the vesicles. 

Points of differential diagnosis between it and acute rheu- 
matism or rheumatic arthritis are : the presence of a gonor- 
rhea ; the fever is much higher in inflammatory rheumatism 



204 GONORRHEA AND ITS COMPLICATIONS 

than it is in gonorrheal arthritis; also the pain is more 
severe and more joints are affected; while in gonorrheal 
arthritis two or three joints may be affected, as a rale only 
one is affected. 

The frequency of the joints affected are as follows, in the 
order named: knee joint, ankle joint, wrist joint, finger 
joint, elbow joint, shoulder joint, hip joint and jaw. The 
knee joint, as said, is the most frequent, furnishing as many 
cases as all the other joints combined. 

The symptoms vary from slight transient pains in and 
about the joint without any inflammation to a severe in- 
flammation with effusion. The effusion may be serous in 
character, sero-fibrinous or purulent. The pain in the 
effused joint may vary from none at all to one almost as 
severe as that of acute articular rheumatism. The attack 
may come on suddenly. There may be a large effusion of 
liquid around the knee joint, the skin over the knee joint 
may be red, and still there may be no pain whatever, either 
spontaneous or on handling and pressing. 

The inflammation may end in resolution, in ankylosis, or 
in abscess, and unfortunately there is a tendency to recur- 
rence. There are some rare cases in which not only the 
synovial membranes of the joint but also the periarticular 
tissues participate, the joint becoming a phlegmonous 
abscess which requires prompt surgical treatment. Such 
cases, however, are rare, and the general practitioner will 
not have many chances to see them. 

TREATMENT 

Frankness demands that we state at the outset that the 
treatment of gonorrheal arthritis can not yet be termed a 



GONORRHEAL ARTHRITIS 205 

brilliant success. We cure many cases, we relieve many 
more, but many cases seem to resist all efforts ; and we are 
unable to predict what cases will be benefited and what cases 
will remain uninfluenced by treatment. Sometimes the ap- 
parently mildest cases laugh at all our efforts, while severe 
cases with joint involvement, where there is even an appre- 
hension that operative measures may become necessary, get 
along very smoothly. 

It is perfectly legitimate to start every case of gonorrheal 
arthritis on salicylic preparations, both internally and ex- 
ternally. We have a right to do so for two reasons. First 
of all, the diagnosis between gonorrheal arthritis and rheu- 
matism is not so absolute that the possibility of error can 
always be excluded. A man with a gonorrhea having pain 
and inflammation in the joints need not necessarily have, 
as stated before, gonorrheal arthritis. A man with gonor- 
rhea can get ordinary rheumatism the same as any other 
man. Then there may be such a thing as mixed rheumatism, 
articular inflammation due to the gonorrheal germ and its 
toxins and to other germs. And second, even in pure cases 
of gonorrheal arthritis the salicylic preparations are of some 
benefit, though of course the benefit is slight as compared 
with the benefit in true rheumatism. I therefore start every 
case of gonorrheal rheumatism with large doses of sodium 
salicylate (15 to 60 grs.), salol (5 to 10 grs.) or aspirin 
(8 to 15 grs). Externally I have the painful parts rubbed 
in with an ointment consisting of methyl salicylate, lard and 
woolf at : 

^ Methyl salicylatis, 5ij (8.0) 

Adipis 

Adipis lanae aa, 3iv (16.0) 



206 GONORRHEA AND ITS COMPLICATIONS 

This is well rubbed in, covered with non-absorbent cotton 
and oiled silk or rubber tissue. The whole is held in place 
by a well fitting gauze or rubber bandage. This treatment 
produces a beneficial effect for three reasons: first, on ac- 
count of the analgesic action of the methyl salicylate ; second, 
on account of the partial immobilization of the joint; third, 
on account of the warmth and the partial passive hyperemia 
induced by the rubber tissue and bandage. 

Instead of the ointment I often have the joints and painful 
parts painted with the following mixture : 

Acidi salicylici, oj (4.0) 
Menthol, gr. xv (1.0) 
Guaiacol, gr. xxx (2.0) 
Alcohol, gi (30.0) 

The joint is painted, then protected with non-absorbent 
cotton, oiled silk and rubber tissue the same as after the use 
of the ointment. 

In some cases inunction with unguentum Crede seems to 
be distinctly beneficial. 

If the salicylic preparations seem to exert no effect we 
may proceed to saturate the patient with calcium sulphide 
(calx sulphurata — sulphurated lime) and arsenic iodide. 
The sulphurated lime may be given in doses of 1 to 2 grains 
three to four times a day, the arsenic iodide in doses of 
Yioo to % g 1 "- three to four times a day. Be sure to get a 
good quality of calcium sulphide or calx sulphurata, because 
much of it on the market is practically nothing but calcium 
sulphate, which is inert. 

Bier's hyperemia is a well recognized procedure in the 



GONORRHEAL ARTHRITIS 207 

treatment of gonorrheal arthritis, and in some cases gives 
very excellent and rapid results. In other cases, however, it 
fails completely. 

Vaccinotherapy. Gonorrheal arthritis is about the one 
complication of gonorrhea in which we are justified in using 
gonorrheal vaccines. Not that the results are so brilliant, 
but they are better than in gonorrheal urethritis and in its 
other complications ; and second, because the disease is often 
resistant to other treatment, and in such cases we are justi- 
fied in doing something. 

Fifty million gonococci should be injected as an initial 
dose (in women and young individuals we may commence 
with 25,000,000), gradually increasing the dose to 500,000,- 
000. The treatment is not to be kept up indefinitely or for a 
period of several months, as I have seen it done in a number 
of cases. A physician with common sense will very quickly 
see whether the treatment is beneficial, remains without 
effect or is injurious. In some cases the mixed gonococcus 
vaccine seems to do better than the gonococcus vaccine 
alone. 

And last but not least the gonococcal foci must be treated 
vigorously. By vigorously I do not mean roughly or stren- 
uously, but I mean gently and persistently. There is no use 
hoping to cure a patient of his gonorrheal arthritis if there 
is an active or even a mild gonorrheal process in the urethra, 
or if there are gonococci in the prostate or in the vesicles. 
The urethra must be irrigated, the prostate and the vesicles 
must be massaged, and everything else possible must be done 
to cure the local lesions and to eliminate the gonococci from 
the system. 

Some surgeons advocate drainage of the seminal vesicles 



208 GONORRHEA AND ITS COMPLICATIONS 

or their removal as a cure for gonorrheal arthritis. I have 
my opinion of vesiculotomy and vesiculectomy, but as these 
are not operations which will be undertaken by the general 
practitioner, for whom alone, we repeat, this book is written, 
it is not necessary to discuss them here. 



CHAPTER XXXI 

GONORRHEA vs. TOBACCO, ALCOHOL 
AND SEXUAL INTERCOURSE 

I know that what I will say here will appear as rank 
heresy. But I have so many heresies to answer for that one 
heresy more or less does not matter. And then heretics 
nowadays are not consigned to the auto-da-fe, nor are they, 
in large cities at least, even in danger of ostracism. So, at 
the present day, it does not require great courage to be a 
heretic or an iconoclast. But I wish to assure my readers 
that I have nothing but the deepest contempt for the icono- 
clast who ridicules old theories and shatters old beliefs 
merely for the purpose of notoriety, merely because he wants 
to shock people, merely because he wants to be in the lime- 
light for a while. That my ideas run counter to the gen- 
erally held beliefs and teachings, is a matter of regret to me. 
But I would not announce them if I were not perfectly con- 
vinced in my mind, and if I could not prove it to my per- 
fect satisfaction, and to fair satisfaction of those who will 
give the matter an unbiased hearing, that they are right 
and beneficial, and that the old theories are wrong and per- 
nicious. 

Though it is a trite statement, for it has been made so 

many times, it is nevertheless true that many text-books do 

not present their authors' actual knowledge and personal 

209 



210 GONORRHEA AND ITS COMPLICATIONS 

experience, but are rather a resume of the other text-books 
in vogue at the given time. When a man who is writing 
on a certain subject has twenty of the most prominent text- 
books before him and finds that all or nineteen of them 
make a certain statement, he will be consciously or uncon- 
sciously influenced by that statement. If his experience 
coincides with the statements of the text-books or if he has 
had no experience in. the line covered by the statement, he 
will of course have no hesitation in reproducing that state- 
ment in his writings. But suppose his experience differs 
from or is even diametrically opposed to the text-book state- 
ments^ — then he thinks that one man 's experience cannot be 
as valuable or as deciding as that of twenty text-book writers. 
He represses his doubts, buries his skepticism — and repro- 
duces the statement of the authorities. He is unaware of 
the fact that all the twenty statements may and generally 
do represent one original source, one original statement that 
has been copied and recopied from one text-book into an- 
other, without real critical analysis ; he is not aware of the 
fact that a "consensus of opinion" is often or occasionally 
but the thoughtless utterance of an unthinking man thought- 
lessly repeated by a thousand other unthinking men. 

GONORRHEA AND TOBACCO 

For years almost every text-book on the treatment of 
gonorrhea told us to be sure to warn our patients against 
the use of tobacco. Has anybody ever seen any injurious 
effect of tobacco on the course of a gonorrhea ? I am sure 
not. And why should there be any? Why should the 
smoking of tobacco aid the development of the gonococci or 
increase the congestion in the urethra and prostate? If 



GONORRHEA VS. SEXUAL INTERCOURSE 211 

tobacco has any effect on the genital sphere, it is that of a 
sedative, a depressant, and therefore cannot exert any in- 
jurious effect. Of course at the beginning of my practice 
I also forbade my gonorrheal patients to smoke ; but I soon 
saw the absurdity of this prohibition. I saw that the non- 
smoking was not only not doing the patient any good, it 
was doing him actual harm. By making him nervous and 
fidgety, by taking away his appetite, by disturbing his sleep 
(some people are so used to their smoke that by depriving 
them of it you interfere with all their somatic functions), 
by interfering with the regular movement of his bowels (to 
some people a smoke is a necessity while in the toilet), his 
general condition was aggravated, and this of course reacted 
deleteriously on the course of the local disease. Since per- 
mitting my patients to smoke ad libitum, I have not had to 
regret it in a single instance, and not only were the patients 
grateful for the permission, but the course of their disease 
was favorably influenced thereby. Of this I am sure. 

GONORRHEA AND ALCOHOL 

What I said about the injunction against smoking applies, 
only with much greater force, to the injunction against 
drinking, i.e., drinking of alcoholic beverages. In every 
textbook, in every article written on the subject it is en- 
joined upon the patient not to touch a drop of anything con- 
taining C 2 H 5 OH in any shape or form. Dire results are 
threatened in the case of an infraction of this injunction. 
That in the acute florid state of gonorrhea alcohol in any 
form is best abstained from is granted; but I emphatically 
deny that there is any valid reason for denying alcohol to 
those suffering with chronic gonorrhea or urethritis. I even 



212 GONORRHEA AND ITS COMPLICATIONS 

question if it is necessary to prohibit alcoholic beverages ab- 
solutely in the declining stage of an acute gonorrhea. 

Though perhaps too personal a matter, it, for certain rea- 
sons, may not be amiss to state here that the writer is prac- 
tically a total abstainer. What he consumes in alcoholics 
would not yield to the government two cents per annum in 
revenue tax. It is not therefore out of personal predilection 
that he pleads for not depriving the patients entirely of 
every kind of alcoholic beverage that they have been used to, 
but because he is convinced that such deprivation often 
works direct and positive injury to the patient. 

Many, many years ago, a member of the tonsorial guild 
told me while trimming my hair that in his opinion the doc- 
tors as a class did not know very much (of course, there were 
exceptions, he hastened to add). He had a gleet, oh, for 
ever so long. He went from dispensary to dispensary, doc- 
tor to doctor, they all gave him different injections and told 
him to keep away from liquor ; but he wasn 't getting better. 
He finally got disgusted, got drunk one evening, kept on 
drinking beer — and very soon he was well. What's more, 
since then he gave that advice, to drink beer, to a number 
of people and most of them got better. Yes, some got worse. 
I smiled then at the ignorance of my barber, but in later 
years I came to think of his story. I had a patient, a 
Frenchman, who from his earliest youth was in the habit 
of taking a glass of claret with his principal meal or meals. 
I forbade him the claret. He was unable to eat. Eating 
without zest, he got dyspepsia, and his bowels became very 
constipated, which made his gonorrhea worse. He went on 
like that for about two weeks, but then he said he could 



GONORRHEA VS. SEXUAL INTERCOURSE 213 

stand it no longer. I permitted him then to have his claret. 
Not only his general condition, but his gonorrhea also im- 
proved. These and similar things set me thinking, and I 
began to observe cause and effect — and I have ceased threat- 
ening my gonorrhea patients with dire consequences if they 
did not abstain from all alcoholic beverages. And I still 
have no cause to regret my liberality in this respect. Many 
cases of chronic urethritis are distinctly improved by the 
moderate consumption of beer and wine. 

GONORRHEA AND SEXUAL INTERCOURSE 

In spite of the elaborate introduction at the head of this 
article, I confess that it is with some trepidation that I ap- 
proach this subject. But it is better to get at once in 
medias res. A decent man with acute gonorrhea, with pro- 
fuse discharge, with ardor urinae, painful chordee, etc., will 
not think of having intercourse. Not that he has no desire — 
the libido is only too frequently heightened in all stages of 
gonorrhea — but common, ordinary decency will restrain him 
from satisfying his desire, even if he did not know that in- 
dulgence might prove injurious to him. But from advising 
abstinence in the acute stage is a wide gap to the strict 
prohibition of all sexual relations during the entire course 
of a chronic urethritis, no matter of how long a duration. 
It is not merely that such abstinence is unnecessary. If it 
were only that, it would hardly be worth while broaching 
the subject. But such abstinence is injurious, injurious to 
the gonorrhea itself, and when this is the case it becomes 
the duty of the physician to speak. And I will say clearly 
that many cases of chronic urethritis, gonorrheal and non- 



214 GONORRHEA AND ITS COMPLICATIONS 






gonorrheal, are unmistakably benefited by sexual inter- 
course. Nor is it hard to understand the reason. A little 
thought will make the rationale perfectly clear. 

A perfectly healthy person, who has led a normally ac- 
tive sexual life, will often, when obliged for one reason or 
another to forego sexual relations for a considerable period, 
begin to suffer from a certain congestion in the genital 
organs. The testicles will feel heavy and painful, there will 
be irritation and radiating pains in the prostatic region, etc. 
These symptoms are much more aggravated in gonorrhea. 
The libido is, as is well known, frequently greatly ex- 
aggerated in gonorrhea. This is due to the local 
congestion in the organs. If a man is suffering from 
subacute or chronic urethritis or prostatitis, and you 
forbid him to have any sexual relations for several 
months, you surely aggravate all his symptoms, increase the 
congestion, and make the local condition much more difficult 
to cure. Sometimes you make a cure impossible. And in 
fact nature often rebels at and scorns your injunctions, and 
to your orders of perfect abstinence she often replies with 
nightly emissions, which hurt a patient much more than 
normal coitus would. It is a well known fact that many 
gonorrheal patients begin to suffer for the first time, during 
their illness, with very annoying and frequently repeated 
pollutions. A little thought will show us that a normal 
coitus accomplishes in a simple, pleasant and complete man- 
ner what we are trying to do therapeutically in a crude, 
painful, incomplete and not infrequently harmful manner. 
In our treatment we try to bring the gonococci hidden in the 
various urethral glands and lacunae to the surface. We do 
this partly with our injections, partly by massage of the 



GONORRHEA VS. SEXUAL INTERCOURSE 215 

urethra, and now we have even introduced the vacuum 
suction treatment, which has this purpose in view. We 
massage the prostate and strip the seminal vesicles — fre- 
quently with quite some traumatism to these two organs — 
and for what purpose ? To free the prostate and the seminal 
vesicles, as far as possible, of the gonococci and the catarrhal 
or purulent products which they may contain. I maintain, 
then, that a satisfying, normal coitus — not coitus inter- 
rupts, or reservatus, or retardatus, but a perfectly normal 
coitus — will accomplish this purpose in a much more com- 
plete manner, and without any injury to the patient. (For 
I must again mention that massage of the prostate and par- 
ticularly stripping of the vesicles, except in very expert and 
gentle hands, is not an' indifferent procedure. The vesicles 
have more than once been irretrievably damaged by rough 
milking or stripping.) He who has had an opportunity of 
examining the prostate and vesicles before and after coitus 
will testify how completely they may be emptied by the 
process of sexual intercourse. Certainly much more com- 
pletely than any massage or stripping ever can. The fact 
that both the subjective and objective symptoms in a chronic 
gonorrheic are frequently markedly improved after coitus 
speaks in favor of the latter. 

Here the hypercritical might interpose: If intercourse 
is not only not harmful but distinctly beneficial in chronic 
gonorrhea, why is it not also beneficial in acute gonorrhea, 
and why not also recommend it in that condition ? Because 
we have an entirely different condition to deal with. In 
acute gonorrhea we have an acute active hyperemia; 
all the blood vessels are overfilled with blood and to 
bring an additional flow of blood would still further 



216 GONORRHEA AND ITS COMPLICATIONS 

distend the blood vessels and erectile tissues, and might 
cause an edema, by transudation. In acute gonorrhea 
we must avoid anything which will cause an erection, 
as the penalty might be a painful chordee. In chronic 
gonorrhea we have but a slight, generally passive localized 
hyperemia; we may even have an ischemia. The effect, 
therefore, is not the same. What is good in one stage of 
gonorrhea might be distinctly injurious in another stage. 
Our critic might as well ask: If a two to ten per cent, 
solution of silver nitrate is so beneficial in chronic ure- 
thritis, why not also use it in acute urethritis? if massage 
is useful in chronic prostatitis, why not use it also in acute 
inflammation of the prostate ? 

So far, I have spoken of the man only. "We now come 
to the woman. The woman must, of course, be protected 
at all hazards. If the woman cannot be protected abso- 
lutely then the man must abstain absolutely, no matter how 
injurious the results of abstinence may be to him. Fortu- 
nately the woman can be protected. A proper condom is 
a perfect protection, but unluckily it is not satisfactory as 
far as the man is concerned. Coitus condomatus does not 
do what we want it to do in emptying the prostate and 
vesicles, and does often leave the man in an unsatisfied and 
irritable condition. This is true of normal men and is 
still more true of men with some venereal and sexual 
trouble. But it is not necessary to depend upon the con- 
dom. A perfectly safe way is the insertion by the woman 
of a mild antiseptic suppository a few minutes before coitus 
(one containing salicylic acid, boric acid, chinosol, etc.), 
and the use after of a mild antiseptic douche. This method 
has been used in very many cases. And there has not been 



GONORRHEA VS. SEXUAL INTERCOURSE 217 

a single case of infection. None has come to my notice, 
and I am certain that I would have heard of them if any 
had occurred, because it was done by my advice, and if 
infection had taken place the responsibility would have 
been thrown on my shoulders. 

I might add here that many men who, soon after marriage 
or on the point of getting married, find that their gonor- 
rhea, which they thought was perfectly cured, is still un- 
cured, have been advised this method, and in no instance 
was a wife ever infected. 

In conclusion I might say that abstinence during a long 
drawn out case of chronic urethritis — an abstinence last- 
ing months or one or two years, for there are cases of 
urethritis lasting that long — has another injurious effect; 
namely, it is apt to affect a man's sexual potency. But 
this is a point that does not belong in this book. 



CHAPTER XXXII 
GONORRHEA IN WOMEN 

When a man has gonorrhea he knows it. "While (having 
learned long ago not to be dogmatic about anything in 
medicine) I do not deny the possibility of a symptomless 
or practically symptomless gonorrheal urethritis in the male, 
still such cases, if at all existent, must be extremely rare. 
This is not, however, the case with women. A woman may 
go through an acute gonorrhea from beginning to end with- 
out knowing it, may have a chronic gonorrhea for years 
without being aware of its existence, often sincerely believ- 
ing that she is perfectly well. A man is not used to having 
pains or burning in his urethra, nor is he used to having 
any discharge from it. At the least pain or scalding, or 
the least appearance of discharge, he knows there is some- 
thing wrong with him. The urethra when infected in 
women does not give as severe symptoms as inflammation 
of the urethra in men, and besides in many cases the female 
urethra escapes infection, the infection being limited to the 
cervix alone or to the cervix and Bartholin's glands. 

A woman is used to pains, the premenstrual pains with 
which many of them suffer are severer than the pains caused 
by the gonorrheal infection ; and they often have a leucor- 
rheal discharge of greater or lesser degree. An increase in 
the amount of secretion or in its color and consistency does 
not attract their attention. It is for this reason that many 

218 



GONORRHEA IN WOMEN 219 

women harbor the gonococcus for months before applying 
to a physician, and some of them never apply at all. It is 
as a rule when the discharge is very profuse, offensive and 
irritating, when urination is painful and burning, or when 
there is a sharp salpingeal attack, that the physician's aid 
is invoked. 

I repeat that many women go through life with a chronic 
gonorrheal cervicitis, with an abundant discharge contain- 
ing numerous gonococci, and use no treatment except an 
occasional douche, because they are under the impression 
that they are suffering from the ordinary leucorrhea or 
"whites" (just as if leucorrhea itself did not require intel- 
ligent medical treatment). 

I do not wish to be understood as claiming that gonorrhea 
in the female is always of a mild character, pursuing a sub- 
acute or symptomless course. I mean to say that such are 
the vast majority of cases which present themselves to the 
physician who has a ''respectable" practice. In the vast 
majority of cases of respectable married women the disease 
pursues such a subacute course. Why? Because in them 
the infection when it takes place is usually the result of 
chronic gonorrhea in the husband. No half-way respect- 
able man will enter matrimony when suffering with an acute 
gonorrhea, and only an exceptionally brutal or weak-minded 
husband, who, straying from the path of marital fidelity, 
has acquired an acute gonorrhea, will continue to have 
relations with his wife. And here is the point I wish to 
make. When the infecting man is suffering with a chronic 
gonorrhea, the infection in the woman usually pursues a 
subacute or chronic course. But when the man has an 
acute gonorrhea then the infection in the woman may from 



220 GONORRHEA AND ITS COMPLICATIONS 

the very beginning assume a superacute, even fulminant 
character. And the rapidity with which the infection may 
show itself is remarkable. While several days usually 
elapse between the infecting intercourse and the first symp- 
toms, there are cases in which the latter show themselves in 
24 hours, and I have had a case where a bride, a girl of 
twenty-one, had her first intercourse at midnight, and the 
following noon she began to complain of burning, irrita- 
tion, scalding urination, etc. In short, the symptoms 
showed themselves in twelve hours after the infecting in- 
tercourse. In her case the gonorrhea proved of a viru- 
lent character; the contributing factors were the frequent 
repetition of the act during the night (five or six times) 
and the violence with which it was performed. The de- 
floration, which leaves an open raw wound, was also a con- 
tributing factor in this case, as it is in many other cases. 

While it usually takes months for a salpingitis to develop 
as the result of gonorrheal infection, there are cases in 
which distinct symptoms of inflammation of the Fallopian 
tubes may develop within a few days, or even within a 
few hours after an infecting intercourse. In such cases 
we are forced to believe in the suction action of the uterus. 
It is impossible to believe that the infection reached the 
Fallopian tubes by continuous extension, within such a 
short period. It is more plausible to believe that the in- 
fection took place by the infecting, gonococci-containing 
material being sucked up into the uterus and into the 
Fallopian tubes. This appears to be more likely from the 
fact that a gonorrheal salpingitis may exist without an 
intervening endometritis or metritis. 

The symptoms in an acute or superacute case of gonor- 



GONORRHEA IN WOMEN 221 

rhea may be very severe. Within several days after an 
infecting intercourse, and sometimes within several hours, 
the latter particularly in young virgin brides and still 
more particularly if the act is performed stormily and 
repeatedly, the woman begins to complain — or if not to 
complain, then to experience, because many of them do not 
complain until their condition becomes unbearable — of a 
burning and itching in the vulva and vaginal introitus, 
of frequent urination, accompanied by strangury, and a 
scalding sensation. A discharge soon makes its appearance, 
which, according to the severity of the case, may be creamy, 
cream-yellow or greenish. It may possess little odor or 
be extremely offensive. It is often very irritating, eroding 
the skin with which it comes in contact and causing pruri- 
tus and intertrigo around the genitals, anus, thighs, etc. 
If proper cleanliness is not observed, the infecting dis- 
charge may invade the anus and a gonorrheal proctitis be 
the result. There is usually an elevation of temperature, 
100° to 102° F., there may also be a chill, and the feeling 
of general malaise may be quite pronounced. If the in- 
fection involves also the Fallopian tubes, then all the gen- 
eral symptoms may be greatly aggravated. The chill may 
be quite severe, the temperature may go up to 103° or 
even 104° F., the abdomen is tender, and the feeling of 
malaise may be so severe as to create apprehension of a 
general peritonitis. 

The diagnosis of an acute or superaeute case of gon- 
orrhea in the female presents no difficulties. The history 
and the symptoms as related by the patient are alone suf- 
ficient. Inspection of the genitals, covered with pus, the 
introduction of a speculum, which shows us an inflamed 



222 GONORRHEA AND ITS COMPLICATIONS 

eroded cervix, bleeding at the slightest touch, and bathed 
in pus which oozes from its external os, make the diagno- 
sis certain. No bacteriological examination is necessary. 

THE TREATMENT 

I know of no condition in medicine where noli nocere 
is more important than in treating gonorrhea of the female. 
It is just as important to know what not to do and not 
do it as it is to know what to do and to do it. In other 
words, negative treatment is here as important as posi- 
tive treatment. In fact abstaining from doing certain 
things is often the more important part of the treatment. 

The great, the paramount point in treating gonorrhea 
in women is to prevent the disease from passing the internal 
os and spreading through the endometrium into the tubes, 
and from there into the ovaries and peritoneum. As long 
as we can keep the gonorrheal process limited to the cervix 
and the other external genitals, gonorrhea is not a ter- 
rible disease. We can handle it without great difficulty 
and cure it eventually, though the time required for a cure 
may in some cases be exasperatingly long. It is when the 
gonorrheal process is extended above the internal os, that 
we become helpless. For after the process has involved 
the endometrium and the Fallopian tubes there is no medi- 
cal treatment; there is only expectant and surgical treat- 
ment, which is of course no treatment at all in the true 
sense of the word. Removing the tubes may be necessary 
to save the patient's life, but to cut out an organ is not 
to cure it. 

Unfortunately it is here that physicians have sinned 
most pitifully. I have no hesitation in saying — it is pain- 



GONORRHEA IN WOMEN 223 

ful to say it but nothing is gained by hiding the truth — 
that a large percentage of cases of endometritis and metri- 
tis, salpingitis, and peritonitis, that thousands and thou- 
sands of cases requiring surgical interference are due di- 
rectly to the physician's well-meant energetic treatment. 
The introduction of syringes and probes into the cervix, 
the scraping and cauterizing with strong caustic solutions, 
are in many instances directly responsible for the exten- 
sion of the inflammation and for the aggravation of the 
patient's condition. Those who know anything about the 
treatment of gonorrhea in women and are not obsessed by 
the furor operandi, know that we get the best results by the 
gentlest methods and mildest applications. 

I consider these prefatory remarks of extreme impor- 
tance, for until the physician is imbued with the feeling, 
saturated with the conviction, that brutality is not a neces- 
sary element in the treatment of gonorrhea, that too ener- 
getic treatment is often injurious instead of beneficial, that 
the uterine cavity must at all hazards be protected from an 
extension of the inflammation, and that he at least mst 
not be the causative factor of that extension, un J he is 
convinced of all these things he is not a safe 
undertake the treatment of a case of gonorrhea in t 

General Treatment. The general treatm of 
gonorrhea in the female can be expressed in i ore 

phrase : rest, taking it easy. If we wish to avoi 
itis or extension of the inflammation abo^\ the nt 
this is a conditio sine qua non. It is unf >rtu ay 

women, and respectable married womf n at 1 itill must 

keep on doing their household work or otfcei work. 

Where it is unavoidable it is unavoidable an lat is all 



224 GONORRHEA AND ITS COMPLICATIONS 

there is to it, but the proper thing would be to put the 
woman to bed, or at least keep her in her room for a couple 
of weeks and have her take things very easy. 

Where there is a considerable rise in temperature or 
symptoms of salpingitis seem to be threatening then put- 
ting the patient to bed is imperative and applying an 
ice-bag to the abdomen is very useful. 

Coitus must be absolutely interdicted. One can think of 
nothing more harmful, more dangerous, than coitus for a 
woman affected with gonorrhea. Intercourse is bad for a 
male with acute gonorrhea, but it is very much more danger- 
ous for a female gonorrheic patient. It not only aggra- 
vates the existing condition, increasing the inflammation in 
the vulva, urethra and cervix, but it is about the surest 
way to cause a salpingitis. I have known cases which were 
progressing very nicely, which were on the point of re- 
covery, but which became suddenly aggravated and in 
which symptoms of salpingitis became evident immediately 
after coitus. So this must be forbidden absolutely in all 
acute and subacute cases of gonorrhea. No exceptions can 
\)e permitted. Whether this extension of the inflammation 
is iue simply to the engorgement of the uterus and other 
geni;al parts induced by the coitus or to a certain suction 
and peristaltic action of the uterus is immaterial. Both 
may be causative factors. The fact remains that coitus 
is a dangerous procedure, which may lead to a fatal issue, 
for a women suffering with acute or subacute gonorrhea. 
A man who forces a woman in such condition to submit 
to intercourse is a criminal brute and the woman who sub- 
mits to it is a pitiful slave. And still the woman is often 
forced to submit to it, the husband thinking that if he 



GONORRHEA IN WOMEN 225 

uses a condom and is not too violent he has done every- 
thing necessary to protect himself and her. 

As far as the diet is concerned, little or no change need 
be made in it if the urethra is not involved. Spices and 
alcohol, however, are best omitted, as they do perhaps 
cause congestion of the genitalia and thus aggravate the 
condition. But where there is a urethritis practically the 
same restrictions are indicated as in gonorrhea of the male. 

As far as internal treatment is concerned, none is nec- 
essary unless the urethra is involved. When the urethra 
is involved and urination is painful, then we may give the 
same balsams, hyoscyamus and alkalies as we do in ure- 
thritis of the male. 

The Local Treatment. If the local treatment in male 
urethritis is important, it is much more so in gonorrhea 
of the female. In fact it is the only part of the treat- 
ment from which definite results can be obtained, the in- 
ternal treatment being merely occasional and auxiliary. 
The treatment to be successful must be of two kinds; one 
administered by the physician, the other administered by 
the patient or to the patient in her home. The home treat- 
ment consists in the use of injections and suppositories. 
The medical treatment, that is the treatment on the part of 
the physician, consists in local applications, that is in 
swabbing and painting the parts, and occasionally in cau- 
terizing. Both parts of the treatment are necessary, as 
they supplement each other. 

As stated before, the home treatment consists in the use 
of vaginal douches and suppositories. The injections that 
I prefer to all others are iodine, lactic acid, and a combina- 
tion of alum, zinc sulphate and copper sulphate. Where 



226 GONORRHEA AND ITS COMPLICATIONS 

the discharge is very profuse the injections should be given 
as often as four times a day. After the discharge becomes 
less profuse, twice a day and then once a day is sufficient. 
The iodine injections are made by adding one tablespoonful 
of tincture of iodine to two quarts of hot water. In some 
cases this is too irritating and we may commence with a 
teaspoonful to two quarts of water. The lactic acid is used 
in the strength of 1-500 to 1-1000. The alum, zinc, copper 
combination has the following formula: 

Aluminis §iv 

Zinci sulphatis Si 

Cupri sulphatis 3iv 

Sig. Tablespoonful to 1 or 2 quarts of water. 

The injections or douches should invariably be taken in 
the recumbent position, the patient lying flat on her back 
on a flat douche pan. It is better when the buttocks are 
raised, so that they are on a higher level than the rest of 
the body. The injection is given very slowly, the fountain 
syringe hanging but high enough to permit the liquid to 
run out. After each injection the patient should remain 
for half an hour or at least fifteen minutes flat on her back. 
This permits some of the liquid that remains in the vagina 
to bathe the vaginal walls and the cervix. In the average 
case I order two vaginal douches a day: in the morning, 
either the iodine or the lactic acid solution, in the evening 
the astringent powder. Where three or four injections a 
day are ordered they are used in alternation. There is no 
doubt as to the good effect of these injections. Not only 
do they keep the parts clean and mechanically remove the 
discharge, which is such a good nutrient medium for the 



GONORRHEA IN WOMEN 



227 



various saprophytic bacteria, but they also have a gono- 
cidal effect, heal erosions and congestions and help* materi- 
ally the doctor's work. 

The nozzle which is used for the vaginal injections is not 
a matter of indifference. I recommend the nozzle, an illus- 
tration of which is reproduced herewith. It possesses two 
important advantages. First, it can close the vaginal 
outlet completely and tightly, so that by closing the clamp 
of the outlet pipe, the vagina can be ballooned out, filled 




Vaginal Nozzle, possessing several advantages 

with the antiseptic solution and every part of the cervix and 
the vaginal folds thoroughly cleansed. Second, with it we 
can use solutions of much higher temperatures than without 
it. As is well known, the vagina and cervix can stand very 
high temperatures ; it is the vulva that is sensitive, and with 
the ordinary pipe or nozzle the heat of the outflowing liquid 
causes discomfort or burning. With this nozzle the out- 
flowing liquid passes through a separate pipe and does not 
touch the vulva. The use of a solution of a high tempera- 
ture (120° F. and higher) possesses a double value. It is in 
itself gonococcocidal, and helps in the absorption of ex- 
udates if any be present. 



228 GONORRHEA AND ITS COMPLICATIONS 

In some severe cases I also order suppositories, one sup- 
pository to be introduced at night. The suppositories usu- 
ally contain as their active constituent either protargol or 
the lactic acid bacillus. The formulas of these supposi- 
tories are as follows: 

Protargol gr. v 

Olei theobromatis 3i 

M. ft. suppos. ovale vel. glob. No. I 
D. Tal. Dos. No. XII. 

Sig. One at night ; to be inserted high up in 
the vagina. 
^ Bacillus bulgaricus tablets, gr. x 
01. theobromatis, gr. xxx 
M. f. suppos. No. I. Tal. Dos. xx 
S. One night and morning. 
Instead of suppositories, the bacillus bulgaricus may be 
prescribed mixed with sugar and blown into the vagina by 
means of an insufflator. 

The Doctor's Treatment. The patient comes to the 
office always immediately after having taken a thorough 
douche. The only time the douche is left out is when the 
doctor wants to make a bacteriologic examination of the 
secretions. He wipes off the vulva, examines carefully for 
any inflamed points or erosions, and if there are any he 
touches them with silver nitrate 10 to 50 per cent., 
or even with the silver nitrate stick. The ducts of Bar- 
tholin's glands are examined carefully, an attempt is made 
to express any pus, and if found necessary they are cau- 
terized with a thin probe or a 10 per cent, silver nitrate 



GONORRHEA IN WOMEN 229 

solution is injected into them by means of a hypodermic 
syringe with a blunted needle. The urethra is next ex- 
amined and if affected is swabbed with a 5 to 10 per cent, 
silver nitrate solution. As a rule the urethra responds to 
treatment very readily. I have no use for any urethral 
bougies or suppositories in women any more than I have 
for them in men. The vagina is next examined with a 
speculum and a good light, and erosions, if any, are touched 
with silver nitrate solution, 10 per cent., or tincture of 
iodine full strength. Lactic acid full strength is also a 
good application. 

We then come to the cervix, which is the most important 
part of the treatment. We wipe it off as carefully as we 
can, introduce several cotton-wound probes and try to re- 
move the cervical plug. The entire cervix is then painted 
with tincture of iodine, and a thin cotton swab dipped into 
tincture of iodine is gently introduced into the os. Care is 
taken not to pass the internal os, though if it should pass 
the danger of extension of the infection would be nil or 
practically nil. Iodine is one of the best agents we have in 
treating gonorrhea in the female, and while I still use sil- 
ver nitrate applications to the vagina, vulva and urethra, 
as far as the cervix is concerned I limit myself exclusively 
to iodine. My results have been much better since exchang- 
ing silver nitrate for iodine, because silver nitrate denudes 
the delicate surface of the cervix and may perhaps be in- 
fluential in causing an extension of the inflammation. In- 
stead of a probe a thin long uterine syringe may be used 
and a few drops of tincture of iodine may be deposited in 
the cervix. 

When the infection has spread into the endometrium and 



230 GONORRHEA AND ITS COMPLICATIONS 

the tubes, then it really ceases to be a genito-urinary and 
becomes a gynecological case. But the gynecological sur- 
geon can do medicinally no more than the ordinary physi- 
cian unless it is a case which demands operation. The 
proper treatment of endometritis and salpingitis is rest, hot 
or cold applications by means of compresses or poultices to 
the abdomen, and tampons of gauze saturated in glycerite 
of boro-glycerin or ichthyol-glycerin or thigenol-glycerin. 
That is all we can do and that is all we should do. In- 
jecting or swabbing the uterus with caustic or strong anti- 
septic applications, scraping or curetting the uterus, all 
these are brutal and useless procedures; not only useless 
but injurious. They may do good in some cases but the 
cases in which they do harm are so much in preponderance 
that no conscientious physician should employ them. We 
can never be sure of removing all the germs by these meas- 
ures, while we are pretty sure to cause their further spread 
and development and to aggravate the inflammation. 
Curetting is not abused so much now as it was formerly, 
but it is still practiced ten times more often than it should 
be. Hot baths, particularly pretty concentrated sea-salt 
baths, are useful in aiding the absorption of exudates. 
And I repeat that unless the case is a distinctly surgical 
case, demanding surgical intervention, this is all the gyne- 
cologist, genito-urinary surgeon or general practitioner can 
do. An attempt to do more is not generally dictated by a 
desire to benefit the patient. 

Vaccinotherapy. The Fallopian tubes not being acees- 
sible to local treatment, we are justified in using antigon- 
ococcic vaccines. They seem to be useful in a small per- 
centage of cases. 



GONORRHEA IN WOMEN 231 

VENEREAL WARTS (CONDYLOMATA 
ACUMINATA) IN WOMEN 

Venereal warts of the acuminate or pointed variety about 
the genitals are due to uncleanliness of any sort, but their 
development is particularly favored by gonorrheal dis- 
charge. Whether they are caused by a special micro-or- 
ganism or are due simply to the irritation caused by the 
gonorrheal discharge, the various cocci found later being 
secondary, has not been determined. 

While venereal warts occur in men too, they are much 
more frequent in women and in them they may attain an 
enormous size. When of large size they show great simi- 
larity in appearance to a cauliflower. Their favorite places 
are the labia, the anus, the clitoris, the vaginal walls and oc- 
casionally the cervix. It is on the labia and around the 
anus where they attain their largest size. Pregnancy 
favors the formation of condylomata acuminata on account 
of the increased vascularity of the parts. While in men 
venereal warts are sometimes dry, they are generally moist 
in women, and are awfully ill-smelling. The smell is some- 
times sufficient to render even the hardened physician sick 
at the stomach. 

In spite of their disagreeable and sometimes formidable 
appearance they are readily amenable to treatment. They 
can be cauterized with the actual cautery or carbolic, chro- 
mic or lactic acid. Either one of the three acids in full 
strength is satisfactory. After the warts have been cau- 
terized either a compress of 1 per cent, of lactic acid, or of 
5 per cent, salicylic acid in alcohol, may be applied. An- 
other method of treating them is spraying them thoroughly 



232 GONORRHEA AND ITS COMPLICATIONS 

with a concentrated solution of resorcin, and then apply- 
ing dry powdered resorcin to every part. A few applica- 
tions of the resorcin shrivels them up and they disappear. 
Excision of the mass, with ligation of the bleeding vessels, 
etc., is in my opinion contraindicated, for I have never 
found it necessary to have recourse to such strenuous meas- 
ures. Painting with pure tincture of iodine or with 20 
per cent, solution of salicylic acid in alcohol will also ac- 
complish the purpose in many instances. 

GONORRHEA AND PREGNANCY 

Pregnancy is of course no barrier against gonorrheal in- 
fection, nor is gonorrheal infection a barrier against preg- 
nancy, though it makes pregnancy less probable, less fre- 
quent. The two may occur at the same time. It unfor- 
tunately happens not infrequently that within the first few 
days of her married life a woman will contract both gonor- 
rhea and pregnancy (contract pregnancy is not the proper 
and accepted term, but I will let it stand, for with some 
women to contract pregnancy is a greater misfortune than 
to contract a disease). I have had a case of a woman of 
twenty-two who both contracted gonorrhea and became preg- 
nant during the wedding night. 

The possibility of gonorrhea not being excluded in the 
most respectable married woman, it should be the duty of 
every physician engaged to attend a case of confinement to 
examine the woman by the aid of a speculum to ascertain 
whether or not she has any discharge, and should there be 
any, to make sure of its character. This is necessary both 
for the sake of the woman, to prevent any gonorrheal flare- 
up in the puerperium, and for the sake of the child to pre- 



GONORRHEA IN WOMEN 233 

vent the terrible misfortune of ophthalmia neonatorum and 
possible blindness. 

If the woman is found to be suffering with gonorrhea, 
then the same measures are to be applied as in a non- 
pregnant woman, except that greater caution is necessary 
in making cervical applications, etc., as too energetic 
handling of the parts may induce an abortion [though it is 
a question whether in a woman suffering from gonorrhea 
an abortion would not be preferable to carrying the child to 
term and subjecting it to the risk of gonorrheal ophthalmia] . 

I emphasized the importance of rest in the treatment of 
gonorrhea in the female. When gonorrhea is associated 
with pregnancy rest becomes doubly important. 

It is in cases where gonorrhea is associated with pregnancy 
that we occasionally see the very worst kind of condylomata 
acuminata. This should be treated according to the rules 
outlined above. 

Gonorrhea in the puerperium may become a very danger- 
ous disease, but generally only on account of the association 
with it of various other bacteria, chiefly the streptococci. 
Douching, ice-bag to the abdomen and rest in bed are the 
principal elements of the treatment. One of the bad re- 
sults of gonorrhea in the puerperium is that it interferes 
with the proper involution of the uterus. This tendency 
must be counteracted by the oral or subcutaneous adminis- 
tration of ergot and pituitary preparations. 



CHAPTER XXXIII 
VULVO- VAGINITIS IN LITTLE GIRLS 






Vulvo-vaginitis is a very common affection among chil- 
dren of the poor, and in institutions. In the latter it used 
to be one of the commonest and most annoying troubles we 
had to deal with, one little girl with vulvo-vaginitis often in- 
fecting an entire ward or dormitory. In former years the 
dangerously infective character of vulvo-vaginitis was not 
known, and infection was readily carried by towels, linen, 
toilet seats, bed pans, bathtubs, syringe nozzles, thermome- 
ters, the nurse's hands, etc. Now very great improvement 
has taken place in this respect, the disease being considered 
as contagious as measles and the greatest care being taken 
in isolating a vulvo-vaginitis patient or pupil from the 
rest. The leading hospitals now do not admit a female 
child to any of the wards without a vaginal smear being 
previously taken and the presence or absence of gonococci 
being ascertained. 

ETIOLOGY OF VULVO-VAGINITIS 

I have not entitled this chapter "Gonorrheal Vulvo- 
vaginitis' 1 and the reason for it will be soon apparent. 
Vulvo-vaginitis means simply an inflammation of the vulva 
and vagina, and it may be due to various causes, such as 
uncleanliness, decomposing smegma, decomposition of urine 
from incontinence, pin worms, trauma from masturbation or 

234 



VULVO-VAGINITIS IN LITTLE GIRLS 235 

attempted rape, etc. Other varieties are due to the pneu- 
mococcus or the diphtheria bacillus. Then there is a ca- 
tarrhal variety which is very infectious and in which the 
gonococcus cannot be found. 

Nevertheless, granting the variety of causes of vulvo- 
vaginitis in children, the chief cause, the cause in the vast 
majority of cases, will be found to be the gonococcus. But 
here is the point, a point which I consider of great impor- 
tance : I claim, as I have claimed for many years, that the 
gonococcus which is found in the vulvo-vaginitis of chil- 
dren is not the same gonococcus with which we have to deal 
in the ordinary gonorrhea of the male or the ordinary gon- 
orrhea of the adult female. It may be that it is not the 
gonococcus at all, but a coccus which presents the morpho- 
logical and cultural characteristics of the gonococcus but 
still possesses an entirely different virulence — or, we will 
say that it is the gonococcus but of a different strain, which 
is merely begging the question. I base my conviction upon 
two facts. If the gonococcus in vulvo-vaginitis of little 
girls were of the ordinary variety with which we are in 
the habit of dealing, the disease would be a much more se- 
vere infection than it is, particularly if we take into con- 
sideration the delicate mucous membrane of the vulva and 
vagina in little girls. As will be seen in speaking of the 
symptomatology, vulvo-vaginitis in children is very fre- 
quently an extremely mild affection. If the virulent gon- 
ococcus were the cause, much more damage, much more pain, 
and much more inflammation would be the result. Sec- 
ond, when we do have to deal with gonorrhea in a little girl 
caused by intercourse, by rape, then the infection is of a 
much more severe character. Of course the rejoinder may 



236 GONORRHEA AND ITS COMPLICATIONS 

be made that in such cases there is an additional element, 
namely the trauma. But there are many cases in which no 
trauma has been inflicted, in which no penetration has taken 
place, where there has been merely contact of the penis 
with the vulva, and still the inflammation is of a much 
severer character. We are therefore bound to maintain 
that the infective germ in so-called gonorrheal vulvovagin- 
itis in girls is a coccus having the morphological and cul- 
tural characteristics of the gonococcus but of much lower 
virulence. 

SYMPTOMATOLOGY 

Generally speaking, vulvo-vaginitis in children is a mild 
infection. A child may have it for several weeks or months 
without being aware of it, without telling anything about 
it, the diagnosis often being made by the mother, who no- 
tices a creamy discharge on the linen or underwear. And 
this is the principal symptom in little girls, the discharge, 
which may be exceedingly profuse, bathing the vulva, va- 
gina and cervix. By looking through a urethroscopic tube 
or a small vaginal speculum the cervix is often found 
bathed in a pool of creamy discharge. There is this great 
difference between gonorrheal infection in little girls and 
adult females, that while the adult vagina is extremely re- 
sistant to the gonococcus, a gonorrheal vaginitis being one 
of the rarest things in practice, the delicate mucous mem- 
brane of the child's vagina offers little resistance to the 
gonococcus and becomes often inflamed and eroded. In 
severe cases there is a simultaneous infection of the urethra, 
Bartholin's glands, the vulva, vagina and cervix, and the 
child may complain of burning at urination, itching and 



VULVO-VAGINITIS IN LITTLE GIRLS 237 

pain around the vulva and anus, and slight pain in the ab- 
domen. There may be a slight rise in temperature, up to 
101° F., and in some instances the attack is sufficiently acute 
to give rise to a chill and fever. A mild arthritis may take 
place within the first weeks of the infection, but as a usual 
thing it comes later on. 

COMPLICATIONS 

Very fortunately, the most serious complication of gon- 
orrhea in the adult female, namely inflammation of the Fal- 
lopian tubes or salpingitis, is so rare in little girls as to be 
practically negligible. Of course it is possible that a mild 
inflammation of the Fallopian tubes takes place, sufficient 
to occlude the opening but not severe enough to give any 
symptoms. This is possible, but as these cases give no sub- 
jective or objective symptoms they cannot be diagnosticated. 
This freedom from salpingitis is due to three causes. The 
complete closure of the internal os offers quite an effectual 
barrier to the passage of the gonococcus ; second, menstrua- 
tion, which is an important factor in favoring the growth 
and spread of the gonococcus, is absent ; third, coitus, which 
is one of the most positive and most injurious factors in 
causing salpingitis — the inflammation often making itself 
apparent almost immediately after a more or less stormy 
sexual act — is here also absent. What is said about sal- 
pingitis also applies to peritonitis, the latter often being a 
consequence of the former. In the very few cases where it 
does take place it is generally localized and followed by rapid 
recovery unless too meddlesome treatment interferes. 

While, as stated, vulvo-vaginitis is a comparatively mild 
infection as far as its symptomatology is concerned, it never- 



238 GONORRHEA AND ITS COMPLICATIONS 

theless has a disastrous effect on the child who is unfortunate 
enough to become a victim of the disease. First of all, it is 
an extremely long disease. It usually takes months, and 
these months may run into years, before a complete cure is 
affected. Second, relapses and exacerbations are quite com- 
mon. Third, the treatment is a disagreeable one for the 
child, and is occasionally painful. Fourth, it has a disas- 
trous effect on the child's morale; most parents, though they 
may love the child most affectionately, look somewhat as- 
kance at it; and continuous vaginal treatment somehow or 
other has a humiliating effect on the child, which begins to 
consider itself as an outcast, as something apart from other 
children. Fifth, the child's education is very frequently 
seriously and permanently interfered with, because it must 
often be taken out of school, whether public or private, and 
private tutoring is of course feasible only for the few. 
Sixth, and this is a point not sufficiently appreciated by the 
profession and the laity, but it is an important point never- 
theless : vulvo-vaginitis in children has unfortunately a dis- 
astrous effect in hastening the sexual maturity of the child. 
Whether this is due to the congestion of the organs pro- 
duced by the inflammation, or to the speculum examina- 
tions, paintings, douches, applications, tampons, supposi- 
tories, etc., the fact remains that girls who suffer from vulvo- 
vaginitis in childhood become sexually mature considerably 
earlier than normal girls of the same class, stratum and 
climate, and their demand for sexual satisfaction is much 
more insistent. Seventh, a mild vulvo-vaginitis may be the 
cause of permanent sterility. 



VULVO-VAGINITIS IN LITTLE GIRLS 239 

PROPHYLAXIS 

It will therefore be seen that vulvovaginitis is a calamity, 
and everything possible should be done to guard female 
children from contracting it. All children should always 
sleep alone. Under no circumstances should a child sleep 
with anybody else, be it a sister, a mother, a friend, a gov- 
erness, or a servant girl. People should be very careful in 
sending their children to spend a night or two with some 
friends. The friends may be all right, but still a friend 
of the friends or a relative of the friends may not be. I 
have known several cases where the origin of the vulvo- 
vaginitis could be traced to little girls spending a week at 
the house of some friends where a boarder or relative was 
infected with gonorrhea. That children should be kept 
away from associating or playing with adults or other chil- 
dren who are known to have gonorrheal infection goes with- 
out saying. The child's genitals should be frequently in- 
spected by the mother, and scrupulous cleanliness by fre- 
quent bathing, sponging with warm solutions and powder- 
ing, should be maintained. The toilet seats in school should 
receive special attention. The wooden seat is a menace be- 
cause it often harbors gonorrheal pus from either the 
female or male genitalia, and the only proper seat is one 
with the anterior portion cut away, the so-called U-shaped 
seat. Such seats should become obligatory in all schools, 
railway stations, dispensaries and other public places. 

TREATMENT 

The treatment of vulvo-vaginitis in little girls is still in 
a very unsatisfactory condition. On account of the small- 



240 GONORRHEA AND ITS COMPLICATIONS 

ness and inaccessibility of the parts, thoroughgoing treat- 
ment is frequently impossible. The noli me tangere super- 
stition that the hymen is something sacred and must not 
be ruptured under any circumstances makes the treatment 
still more difficult. Strictly speaking, vulvo-vaginitis 
should be a hospital disease, but on account of the length of 
time required for a cure this is frequently impracticable or 
impossible. But a competent nurse, or barring that, a firm 
intelligent mother, is a sine qua non. 

The keynote of the treatment of the vulvo-vaginitis of 
children, as well as of gonorrhea in adult females, is gentle- 
ness. Whatever we do we must do no harm, and certainly 
we must do nothing which may favor an extension of the in- 
flammatory process above the internal os. The treatment 
of vulvo-vaginitis in children consists in cleanliness, ir- 
rigations of the vaginal canal, instillations and suppositories. 

Locally, erosions, if any, must be touched up with silver 
nitrate or iodine. The vulva should be washed several times 
a day, depending upon the amount of the discharge, and 
protected with a gauze pad, over which a pair of drawers 
or knickerbockers are used which the child itself cannot 
undo. The washing of the vulva may be done with plain 
soap and water or boric acid solution, or a solution of alu- 
minium acetate. 

Irrigating the vagina should be done by the aid of a 
fountain syringe and a small glass nozzle. About a pint of 
a solution should be used at a time, and the pressure should 
be low. The best solution for vaginal injections is a weak 
1-1000 lactic acid solution or a weak solution of tincture 
of iodine (y 2 to I teaspoonful to a quart of water). We 
do not expect to destroy all the germs by the vaginal in- 



VULVO-VAGINITIS IN LITTLE GIRLS 241 

jections, but we do destroy some; and besides, leaving the 
pus in the parts produces erosions, chafing, and gives rise 
to condylomata acuminata. So even the mechanical re- 
moval of the pus does good. 

Where an inspection of the vagina shows erosions (and 
no treatment can be satisfactory unless inspection is made 
by means of a small vaginal speculum — not a urethroscopic 
tube — and strong light) they must be touched up with a 10 
per cent, silver nitrate solution or with full strength tinc- 
ture of iodine. 

After thorough douching, it is well to instill in obstinate 
cases 30 to 60 minims of a 5 per cent, protargol solution, 
or a 2 per cent, silver nitrate solution. As conditions im- 
prove the instillations need only be repeated once or twice a 
week. 

While I have no use whatever for suppositories and bou- 
gies in male gonorrhea, they are of some use in gonorrhea in 
the female, and I often prescribe a small 2 per cent, pro- 
targol suppository as follows: 

Protargol gr. ss 

Acidi borici gr. v 

01. theobromatis gr. xxv 

M. f. suppos. No. i. Tal. Dos. No. xxx 
Sig. One suppository at night. 

From the use of kaolin or kaolin and yeast I have ab- 
stained in little girls : first, because they are difficult of in- 
troduction and application; second, the powder forms hard 
concretions which are difficult of removal, which is not the 
case with adult females. 



242 GONORRHEA AND ITS COMPLICATIONS 

Vaccines I do not use at all, for I have not found them of 
the slightest value. They frighten the child and cause it 
unnecessary pain without producing the slightest beneficial 
effect. I am glad to see that other investigators are coming 
to the same conclusion. 



CHAPTER XXXIV 

GONORRHEAL OPHTHALMIA — GONOCOCCAL 
INFECTION OF THE EYE. OPHTHALMIA 
NEONATORUM. OPHTHALMIA OF THE 
NEWBORN 

I did not intend to devote any space in this book to a dis- 
cussion of gonorrheal infections of the eye, for in my opinion 
eye affections of all kinds, and particularly those of any 
seriousness, should be treated by a specialist and not by a 
general practitioner; and in the large cities gonorrheal in- 
flammations of the eye are immediately referred to an 
ophthalmologist. But I recollected that this book is written 
for the general practitioner in all parts of the country, and 
there are thousands of places where no specialist is available. 
With or against his will, the general practitioner is forced 
to treat such cases, and it is therefore necessary to include a 
chapter on the subject. 

Gonorrheal ophthalmia in adults is generally due to direct 
infection by the fingers, soiled towels, etc. While metastatic 
infection of the eye, by the toxins reaching the organ through 
the circulation, is not an impossibility, still such cases are so 
rare that they may be disregarded. In newborn infants the 
infection takes place directly, by the eyes touching the cervix 
and vaginal canal or by the infecting material being trans- 
ferred from the baby 's body. There are also cases where the 

infection of the infant's eyes takes place in utero, the 

243 



244 GONORRHEA AND ITS COMPLICATIONS 

gonococcus penetrating the unruptured membranes, or the 
membranes rupturing prematurely. In such cases the in- 
fant is born with a fully developed ophthalmia, or it may 
even be born totally blind. Fortunately such cases are rare. 

Prophylaxis. Here if anywhere prophylaxis is infinitely 
more important than cure. I make it a rule to instill in 
every adult gonorrheic a wholesome fear of infecting his 
eyes. I tell him — and her — that carelessness may mean the 
loss of the eyesight, and I give them instructions how to be 
careful, how to wash their hands after touching the genitals, 
even ever so lightly (see Instructions to Patients, in the 
chapter on "The Treatment of Gonorrhea"). And I can 
assure you that they follow instructions. Nothing people 
are so much afraid of losing as their eyesight, except their 
minds. 

It is stated, and the statement may be accepted as correct, 
that in civilized (?) countries about one-third of all the 
blindness is due to ophthalmia neonatorum. The horrible- 
ness of the disease therefore requires no emphasis, no dis- 
cussion. And its prophylaxis becomes a matter of the great- 
est importance, imposing a grave responsibility upon every 
attendant connected with bringing a child into the world.* 
The mother if afflicted with gonorrhea must be treated with 
frequent non-irritating but mildly antiseptic douches, etc. 
But even if the discharge is apparently purely leucorrheal, 
treatment should not be neglected. For a leucorrheal dis- 
charge may also give rise to infection. 

The child as soon as delivered must be given special atten- 

* The somber subject of blindness from gonorrheal ophthalmia in 
the newborn has been the theme of several stories. It is treated in 
"The Rise of Richard Martindale" in the author's "Stories of Love 
and Life"; also in Upton Sinclair's "Sylvia's Marriage." 



GONORRHEAL OPHTHALMIA 245 

tion with reference to its eyes. If we have known the 
mother before delivery and are sure that she is all right, then 
merely wiping (wiping always away from the eyes, and not 
towards them !) the infant's eyes with cotton swabs wet with 
boric acid or saline solution is sufficient ; but where we sus- 
pect or know that the mother has had a gonorrheal discharge, 
then besides the preliminary cleansing we must instill into 
each eye some gonococcocidal solution. Crede may well be 
considered one of humanity 's great benefactors, for by his in- 
vestigations and teachings he has saved the eyesight of thou- 
sands and thousands of children. In cases that are strongly 
suspicious it is still advisable to stick to his original recom- 
mendation — the instillation into each eye of two drops of a 
2 per cent, solution of silver nitrate. 

In the general run of cases, however, a 1 per cent, solution 
of silver nitrate (1 drop in each eye) is sufficient. Instead 
of the silver nitrate we may use a 5 per cent, solution of 
sophol or protargol or a 15 per cent, solution of argyrol. 
These organic silver compounds have the advantage over 
silver nitrate of being but slightly irritating. To judge by 
the latest reports, sophol is the best of all silver preparations 
both in the prophylaxis and the cure of ophthalmia neon- 
atorum. 

Diagnosis. The diagnosis of gonorrheal inflammation of 
the eye is not difficult. The disease starts with a red in- 
flamed conjunctiva and with an excess of secretion, which 
may be serous in the beginning but soon becomes purulent. 
The eye is badly swollen and glued together. It is some- 
times so strongly glued together that it requires quite some 
washing and manipulating before the lids can be separated. 
The separation of the lids is always a disagreeable, painful 



246 GONORRHEA AND ITS COMPLICATIONS 

process, and sometimes there is so much pus behind the glued 
lids that when they are opened the pus spurts out. The 
doctor, the nurse or whoever attends to a child or an adult 
with gonorrheal ophthalmia must very carefully guard 
against infection by the pus. The finding of the gonoeoccus 
in the pus make the diagnosis positive. 

Treatment. The treatment of gonorrheal inflammation 
of the eye must be exceedingly gentle and at the same time 
exceedingly vigorous, the word ' ' vigorous ' ' referring to the 
continuous, unremitting care and watchfulness. 

If only one eye is affected the first thing to do is to pro- 
tect the other eye with a Buller's shield, which is simply a 
watch-glass held down over one eye with strips of adhesive 
plaster. But the eye must be watched carefully, and as soon 
as signs of inflammation in it appear, as they unfortunately 
only too often do, the shield must be removed and the eye 
treated like the other eye. 

The treatment consists in very frequent — some prefer con- 
tinuous — irrigation or washing of the eye with a 2 per cent, 
solution of boric acid or 1 per cent, solution of sodium 
chloride. The water should be warm, of a temperature be- 
tween 100 and 110, and poured from a glass vessel with a 
spout or from an irrigator hanging very low. The force 
with which the water touches the eye must be very slight. 
The washing or irrigation should be done every hour or half- 
hour, or after decided improvement has set in every two 
hours. Besides the washings or irrigations, instillations 
into the eye of a gonococcocidal solution is absolutely neces- 
sary. A 2 per cent, solution of silver nitrate is efficient, 
but on account of the pain it sometimes causes it is often 
difficult to apply thoroughly. To derive the full benefit of 



GONORRHEAL OPHTHALMIA 247 

the application the eye-lid must be fully everted and the 
solution dropped in ; otherwise it touches only a portion of 
the eye-lids and the rest is squeezed out. Instead of silver 
nitrate solution we can use with great satisfaction a solution 
of sophol 5 per cent., protargol 5 per cent., or argyrol 25 
per cent. These instillations are to be repeated every two 
to four hours. 

Where the cornea is involved the instillation of atropine 
sulphate or eserine sulphate (2 to 3 drops of a % per cent, 
solution) is necessary. 

The treatment with the irrigations and instillations must 
be continued, though at rarer intervals, for several days after 
all signs of pus have disappeared, because it is possible that 
the gonococcus may remain somewhere dormant and by dis- 
continuing treatment too soon a recrudescence of the inflam- 
mation may take place. 

METASTATIC GONORRHEAL CONJUNCTIVITIS 

There are patients who with each fresh attack of gonor- 
rhea get a conjunctivitis of greater or lesser severity. Of 
course it is possible that the conjunctivitis is due to direct 
contagion but that its mildness is due to a very low grade 
inflammation, the inflammation being mild on account of a 
certain amount of immunity developed within the patient, 
but it is hardly likely. If the gonococcus penetrates into 
the eye it generally causes a good deal of mischief. We are 
justified therefore in assuming that this conjunctivitis is 
due to a metastatic infection, to the action of gonotoxins 
circulating in the blood on the conjunctiva. The treatment 
consists in warm or cold boric acid compresses, and in the 
instillation into the eye of a few drops three times a day of 



248 GONORRHEA AND ITS COMPLICATIONS 

a mild zinc sulphate solution: zinc sulphate one or two 
grains, water one ounce. The following is a good formula : 

^ Zinc sulphate gr. ij 

Boric acid gr. x 

"Wine of opium m. x 

Distilled water §1 

Sig. Three drops into the eye 3 or 4 times a day. 

NOT ALL. CASES OF OPHTHALMIA NEONATORUM DUE TO 

THE GONOCOCCUS 

Before concluding this chapter I consider it necessary to 
emphasize one point, namely that not all cases of ophthalmia 
neonatorum are due to gonorrheal infection. Ignorance of 
this point may lead to the gratuitous breaking up of a home. 
A little knowledge is a dangerous thing. In former years 
women knew nothing about such matters. Whether them- 
selves diseased or whether their children lost their eyesight 
a few days after birth, it did not come to their minds to con- 
nect these things with their husbands : it was a dispensation 
of Providence, and that was all. Now they have learned 
something. They know that the husband's past may have 
something to do with their or their children's illness. 
But they have gone to the other extreme and, like 
all people with little knowledge, they are apt to take 
any little information they have gathered for absolute. 
A large percentage of cases of ophthalmia neonatorum 
is due to gonorrheal infections, but not all by any 
means. What the exact percentage is cannot be defi- 
nitely determined. It is probably somewhere between 
60 and 75 per cent., and the other 25 to 40 per cent. 



GONORRHEAL OPHTHALMIA 249 

are not due to the gonococcus at all, but to infection with 
other germs, chiefly the streptococcus. It is important that 
the good wife should know that when a child is born afflicted 
with the terrible disease of ophthalmia neonatorum it does 
not necessarily mean that her husband had infected her with 
gonorrhea. The husband may never have had gonorrhea, 
the cause may lie in her own vaginal discharge. Only an 
extremely careful and repeated bacteriologic examination 
can determine with absoluteness whether the discharge in a 
case of ophthalmia neonatorum is due or is not due to the 
gonococcus. 



RARE COMPLICATIONS OF GONORRHEA 



Such complications of gonorrhea as pyemia, septicemia, 
endocarditis, metastatic abscesses in remote parts of the 
body, erythema and various other eruptions, need only be 
mentioned here. It is good that a physician should know 
that such complications are possible. They are, however, 
so rare that he is not likely ever to have an opportunity of 
seeing a case. If he should see them, they are to be treated 
on general principles, like any other pyemic or septicemic 
infection, or like abscesses in general. Vigorous vaccine 
treatment will of course be unavoidable in such cases even 
if the results are not very promising. 

The eruptions need no special treatment, but it is well to 
bear them in mind, so as not to mistake them for a syphilitic 
roseola or other syphilitic eruption, and in treating a case of 
gonorrhea it is also well to bear in mind that copaiba, cubebs 
and even santal-wood oil may occasionally give rise to a 
severe erythema and other rashes. 



250 



CHAPTER XXXV 

MINOR POINTS* 

When a patient voids cloudy urine be sure that the cloudi- 
ness is not due to phosphates before telling him he has 
cystitis. Add a drop or two of nitric acid to every cloudy 
urine. 



In examining a patient's urine voided in the office place 
the glass receptacle in front of a gas flame or electric light. 
The smallest shreds and the faintest clouds of mucus can 
thus be detected. 



When a patient is unable to void his urine in the office, 
leave him alone in the room, taking care to let him hear the 
trickling stream of a slightly open water faucet nearby. 
With some patients you need only to strike a certain ' * note 
with the water faucet, and "off they go." 



•> t 



Pain at the end of the penis is usually referred from the 
prostate or the neck of the bladder. Such a pain occurs in 
prostatitis, in stone or gravel. 



Urethral caruncle in women is a cause of frequency of 

* Taken principally from the author's American Journal of Urol- 
ogy, Venereal and Sexual Diseases. 

251 



252 GONORRHEA AND ITS COMPLICATIONS 

micturition. Do not forget to look for its presence before 
sending your patient to a specialist for cystoscopy. 



Frequent micturition in women may occur without any 
changes in the urine and without any lesions in the bladder, 
as a result of uterine abnormalities. 



When prescribing injections for acute gonorrhea be sure 
to tell the patient how much fluid to inject. The pain or 
burning sensation of an injection into the anterior urethra 
depends upon the amount of distention of the acutely in- 
flamed mucosa, and hence even plain water injected forcibly 
or in too large amount will cause discomfort. 



The normal healthy anterior urethra of an adult holds 
about 10 to 18 c.c. The inflamed urethra holds comfortably 
only 8 to 10 c.c. A urethral syringe should hold 12 c.c. 
(i.e., 3 drams) and the patient should inject only half its 
contents at first, during an attack of acute urethritis. 



No one can swear that a Gram negative diplococcus which 
has all appearances of Neisser's germ is a gonococcus un- 
less the organism be grown in cultures by an expert in 
bacteriology. And even then there may be just a wee bit of 
doubt. 



A negative culture test in a man who is about to marry 
does not insure his wife against gonorrhea any more than 
does a negative Wassermann test insure her or her child 
against syphilitic infection. 



MINOR POINTS 253 

A chronic localized patch of urethritis, especially in the 
neighborhood of a stricture, will give a recurrent discharge, 
lighted up by sexual excitement or by alcoholic indulgence. 



Non-specific urethritis may be caused by intercourse with 
a woman during menstruation, but in all such cases be sure 
to look for gonococci. If any were present in the uterus or 
cervix they are apt to come out of their lair just at the time 
of the periods. 



A solution of argyrol to be effective must be perfectly 
fresh. After it has stood six hours or more its effect begins 
to grow less trustworthy. This holds good with practically 
all the newer silver salts. Dark, well closed bottles and a 
dark corner are preventives against decomposition. 



Always test the resiliency of a soft rubber catheter before 
introducing it. If the rubber warps or cracks do not use 
the catheter, unless you wish to risk having a piece remain 
in the bladder when you withdraw the instrument. 



If a soft rubber catheter, especially an old one that has 
been boiled often, "gets stuck" in the grip of the vesical 
sphincter or of a stricture when you attempt to withdraw 
it, inject hot water into the urethra alongside the catheter, 
by means of a large piston syringe. The heat and pressure 
of the water will loosen the tight grip on the catheter and 
it will slip out easily. 



A good way to give prolonged urethral injections (lasting 
fifteen minutes) is to fill the urethra with the solution, 



254 GONORRREA AND ITS COMPLICATIONS 

allowing the fluid to be retained for five minutes ; then let 
the fluid out and repeat the injection with fresh solution, 
to be retained five minutes. The solution is then again 
allowed to escape and the process repeated with a fresh 
portion for five minutes more. This method has the advan- 
tage of preventing unduly prolonged strain upon the 
sphincter and thus avoiding possible entrance of fluid into 
the posterior urethra. 



By keeping a urethral injection in the canal for fifteen 
minutes or longer the effect on the gonococci is greatly en- 
hanced. Injections squirted in and squirted out at once 
have very little effect. 



Remember that in dilating strictures with progressively 
increasing sizes of instruments the safest way is to introduce 
at each treatment a sound or bougie of the size already used 
at the previous treatment, and then only to replace this 
smaller size by the next larger instrument. Never increase 
more than one or two numbers at each sitting. 



The best time to pass sounds and other urethral dilating 
instruments is in the evening, when the patient can go home 
and rest, instead of continuing to go about his daily work. 



Never use a sound roughened by frequent boiling or rusty 
from neglect. Avoid rusting by wiping sounds dry while 
they are hot. 



The "penetrating action" of silver salts, which is so fre- 
quently praised, is not needed in the posterior urethra as 



MINOR POINTS 255 

much as in the anterior. In the posterior urethra silver 
nitrate acts better than in the anterior, while in the latter 
the newer silver salts are to be preferred, as being more 
penetrating. 



A periurethral fistula, or a paraurethral infected glan- 
dular pocket will prevent recovery from chronic urethritis 
and is always an open door for a reinfection. Cure all such 
complications thoroughly before you dismiss your patient 
for better or for worse. 



Urethroscopy is worthless except in the hands of a man 
who knows what he sees when he sees it. 



Even an expert can tell very little by looking through a 
urethroscopic tube of a caliber less than 26° F. The best 
results for anterior urethroscopy are obtained with a tube 
28° F. or larger. 



The success of Gram's stain depends on (1) a thin smear 
uniformly spread; (2) an overstaining with a freshly pre- 
pared anilin gentian violet solution; (3) a decolorization 
which is not too prolonged to take the dye out of the Gram 
positives; (4) under-staining with a dilute contrast stain. 



Do not hope to cure a chronic gonorrhea as long as the 
patient has a pin-point meatus or a long tight foreskin, for 
these are the two great handicaps in the race to recovery. 



Individuals vary greatly as regards the temper of their 
urethra. Always acquaint yourself with the amount of 



256 GONORRREA AND ITS COMPLICATIONS 

reaction, the degree of pain produced, the extent of dilata- 
tion permissible in any individual patient before using in- 
struments boldly in his urethra. 



It is a patient's inalienable right to be protected against 
infection, especially venereal infection in your office. Be 
sure to boil the tips of irrigators, syringes, etc., before using 
them. 



Nervous and over-anxious patients often demand daily 
treatment with urethral instruments "to hurry the cure." 
Do not be weak enough to let them come oftener than is 
necessary or advisable. 



Over-treatment is the curse of the amateur urologist. Ex- 
perience teaches that much harm and no good can come 
from too much local interference in urologic conditions. 



Never neglect internal and general treatment in your 
venereal cases. Remember that iron, quinine, arsenic, cod- 
liver oil, etc., are made not only for the "medical case," 
but also for the genito-urinary patient. 



Patients with strictures of the bulbous urethra must re- 
port to the surgeon once or twice a year indefinitely, for 
the passage of a full-sized sound, after they have been dis- 
charged as cured. They are the men whom Bazy has aptly 
called "the perpetual subscribers" to dilatation. 



MINOR POINTS 257 

COMPARISON OF URETHRAL SCALES 

French English American French English American 



14 


7 


9 


25 


14 


16 


15 


7 


10 


26 


15 


17 


16 


8 


11 


27 


16 


18 


17 


9 


11 


28 


17 


19 


18 


9 


12 


29 


17 


19 


19 


10 


13 


30 


18 


20 


20 


11 


13 


31 


19 


21 


21 


12 


14 


32 


19 


21 


22 


12 


14 


33 


20 


22 


23 


13 


15 


34 


21 


23 


24 


14 


16 









THE MATERIA MEDICA OF GONORRHEAL AND 
NON-GONORRHEAL URETHRITIS AND 
THEIR COMPLICATIONS 

It has been observed that physicians who were phar- 
macists before they embraced the medical profession are 
usually successful above the average, particularly in the 
treatment of diseases in which drugs play an essential 
role. I have always claimed that a brief course of phar- 
macy should constitute an integral part of the medical 
curriculum. The physician who knows his drugs not 
merely from textbooks, but has a practical familiarity with 
them, knows how they look, how they smell, how they be- 
have in relation to each other, their solubilities, their in- 
compatibilities, is a more successful practitioner than he 
who is ignorant of these matters. He can help himself, he 
knows better how to prescribe, and he often can show some 
originality in his combinations. Quite the contrary is the 
case with physicians who know their pharmacology or ma- 
teria medica only theoretically and have no idea of prac- 
tical materia medica and pharmacy. They must be slaves 
to the textbook prescription, and when they do make an 
attempt at originality they often bungle in a most ludi- 
crous manner. This is true even of some of our foremost 
urologists. It is pitiful to see their unfamiliarity with 
some of the drugs they prescribe, while of many valuable 

258 



MATERIA MEDICA 259 

drugs and combinations they know not even the name. It 
is for this reason that some of them have recourse to sur- 
gery, or instrumentation where a simple drug combination 
properly administered would suffice. 

I believe that a physician should have a thorough or at 
least a good knowledge of the tools he handles. His drugs 
are his tools, and I therefore have incorporated in this book 
a section dealing with the drugs used externally and in- 
ternally in the treatment of gonorrhea and its complica- 
tions, giving an idea of their physical appearance and 
properties, solubility, incompatibilities, dosage, undesirable 
sequelae, etc. The physician need not read this section at 
one sitting, but when he comes across a drug, with which 
he is unfamiliar, mentioned in this book, he should refer 
to it. 



CHAPTER XXXVI 
SILVER SALTS--INORGANIC AND ORGANIC, 

Argenti Nitras. Silver Nitrate 

Colorless transparent crystals becoming gray or almost 
black on exposure to light and very soluble in water (in 
half a part, that is, it requires only about half an ounce of 
water to dissolve an ounce of silver nitrate) . But the salt 
and its solutions should be kept in amber colored bottles 
protected from light. It is at once precipitated by soluble 
chlorides even in very dilute solutions, and is therefore of 
course incompatible with sodium chloride, cocaine hydro- 
chloride, etc. But we take advantage of this property 
when we want to neutralize an excess of silver nitrate 
which has been injected or applied externally. 

In the office silver nitrate is best kept in a 10 per cent. 
solution. But only as much stock solution should be made 
up as can be used up in 2-3 weeks. 

In the treatment of urethritis silver nitrate occupies the 
first place. It is not a sovereign remedy, it is not free 
from decided disadvantages — for it causes pain and irrita- 
tion — but if carefully and judiciously used it will do as 
much as any remedy can do, and in chronic urethritis it 
will do what no other remedy so far discovered can do. 
And if I were limited, in the treatment of gonorrheal ure- 
thritis to one single drug, I would select silver nitrate. 
Its uses are so numerous and so varied that a detailed men- 

260 



SILVER SALTS— INORGANIC AND ORGANIC 261 

tion of them will be found only in the text ; here suffice it 
to say that its varied indication will be seen from the fact 
that the strengths in which it is used vary from 1 in 20,000 
to 1 in 10! 

Argenti Iodidum. Silver Iodide 

Numerous attempts have been made to introduce this 
salt in various forms — concentrated solution, emulsion, 
tablets — in the treatment of gonorrhea, but as it does not 
seem to possess any advantages which would compensate 
for its disadvantages, the attempts are given up and the salt 
is again forgotten. I have given it a trial, but have dis- 
carded it. 

Albargin. Silver Gelatose 

A compound of silver nitrate with gelatose containing 
13 to 15 per cent, of silver. Coarse brownish yellow pow- 
der, readily soluble in water. Incompatible with chlorides. 
Used in 1-10 to 1 per cent, solution for injection. In the 
abortive treatment Blaschko uses solutions as high as 2 per 
cent. On the market in 3 grain (0.2 gm.) tablets which 
are convenient for making fresh solutions. 

Argentamin. Argentamin Solution 

This is a solution prepared by dissolving 10 parts each 
of silver nitrate and 10 parts of ethylene-diamine in 100 
parts of water. It is a colorless liquid turning yellow on 
exposure to light; not precipitated by chlorides. Used as 
injection in % to 1 per cent, solution, as instillation in 1 
to 4 per cent, solution. 



262 GONORRHEA AND ITS COMPLICATIONS 

Argonin. Silver Casein 

A compound of silver and casein containing 4.28 per 
cent, of silver. Fine whitish powder, readily soluble in 
water, forming an opalescent solution. Clearly soluble in 
a sodium chloride solution. Incompatible with acids. 
Used in % to 2 per cent, or stronger solutions. 

Argyrol. Silver Vitellin 

A silver oxide proteid, containing from 20 to 25 per cent, 
of silver. Black scales, very hygroscopic, freely soluble in 
water and glycerin, insoluble in oils. Leaves a black stain 
on the skin and clothes ; fresh stains are readily removed by 
solution of mercuric chloride. Incompatible with acids 
and most salts. 

Used in acute gonorrheal urethritis and in cystitis in 
strengths of 5 to 25 and even up to 50 per cent. Its anti- 
gonorrheal properties are beyond question, but its value 
has been greatly overrated. As a rule it is non-irritating, 
but there are numerous exceptions. We have seen many 
cases aggravated by its use ; we have seen it produce severe 
strangury and hemorrhage. Keyes states that he has seen 
two cases of prostatic abscess due to its intemperate use. 
It has no germicidal effect on the gonococci, but if used in 
fresh and not too strong solutions (no stronger than 5 to 
10, and only exceptionally 20 per cent.) it generally has 
a sedative soothing effect, which is of value in acute gonor- 
rhea. Argyrol is worthless in chronic gonorrhea or in any 
form of non-gonorrheal urethritis. 

Cargentos. Colloidal Silver Oxide 
Contains 50 per cent, of metallic silver in the form of 



SILVER SALTS— INORGANIC AND ORGANIC 263 

silver oxide combined with a modified casein. Black scales 
readily soluble in water and glycerin; (cargentos does not 
really form a solution but a very fine suspension) . Not pre- 
cipitated by soluble chlorides. Used in strengths of 5 to 25 
per cent, in acute gonorrhea. The suspensions should be 
freshly prepared. Also on the market in the form of 3 grn. 
(0.2 gm.) tablets, which are convenient for preparing solu- 
tions extemporaneously in the office; the tablets must be 
crushed or powdered, sprinkled on cold water, permitted 
to stand for about five minutes and then stirred or shaken 
until perfect suspension results. 

Cargentos urethral suppositories. Each suppository con- 
tains 2 grains cargentos, in a vehicle of glycerite of boro- 
glycerin and gelatin. 

Collargol. Colloidal Silver 

An allotropic form of metallic silver, containing about 
85 per cent, of silver, with a small percentage of albumin 
to make its solutions more stable. Readily soluble in 
water, forming a dark brown solution (or suspension) 
which remains stable for months. While collargol (and 
particularly collargol ointment) has many uses in various 
infections, gonorrhea is not its field. I have given it a 
trial in a few cases but with indefinite results. 

Hegonon 

Hegonon is a combination of silver ammonium nitrate 
with albumose containing about 7 per cent, silver. Light 
brown powder readily soluble in water; the solution does 
not coagulate albumin, nor is it precipitated by chlorides. 
For irrigations it is used in solutions of 1 in 8000 to 1 in 



264 GONORRREA AND ITS COMPLICATIONS 
2000, and as an injection in strengths of 1 in 500 to 1 in 200. 

Ichthargan. Silver Ichthyol 

A combination of ichthyol and silver, stated to contain 
30 per cent, of silver. Brown powder freely soluble in 
water and glycerin. Incompatible with chlorides. As in- 
jection in acute gonorrhea used in strength of 1 :2500 to 
1 :500. In chronic gonorrhea in 1 to 3 per cent, solutions. 
I could never convince myself of any advantages of this 
silver compound. 

Largin 

Largin, a silver-protalbin combination, containing 11 
per cent, of silver. Gray powder, soluble in 10 parts of 
water. Used in gonorrhea in % to 2 per cent, solutions. 
Has little to recommend it. 

Nargol. Silver Nucleid 

Nargol is a combination of silver with yeast nuclein, 
containing about 10 per cent, of silver. Readily soluble 
in water. The solution is not precipitated by sodium 
chloride, nor does it coagulate albumin. Not decomposed 
by hot water. Used as injection in acute gonorrhea in % 
to 1 per cent., in chronic gonorrhea in 1 to 5 per cent., 
strength. Also on the market in the form of one and two 
per cent, urethral bougies. 

Novargan. Silver Proteinate 

A silver albumin compound containing 10 per cent, of 
silver. Yellow powder, soluble in water, not precipitated 
by soluble chlorides. As an injection in 2 to 10 per cent, 
strength. As an instillation in 10 to 20 per cent, strength. 



SILVER SALTS— INORGANIC AND ORGANIC 265 

In the latter form it has been particularly recommended in 
the abortive treatment of gonorrhea. 

Omorol 

Omorol is an albuminate of silver, containing 10 per cent, 
of the metal, insoluble in water, but soluble in a sodium 
chloride solution. It has hardly been used in gonorrhea. 

Picratol 

Picratol is a compound of silver and picric acid: silver 
picrate, silver trinitrophenolate ; contains 30 per cent, of 
silver. Yellow floccules, soluble in 50 parts of water. 
Used in % to 2 per cent, solutions. 

Protargol. Silver Proteid 

A compound of silver and albumin containing 8.3 per 
cent, of silver organically combined. A light brown pow- 
der slowly but completely soluble in two parts of water. 
The best way to prepare a solution is to sift or sprinkle 
the required amount of protargol on the surface of required 
amount of cold water in a graduate, and let it stand for 
a few minutes when solution will be effected. The solu- 
tion is not precipitated by sodium chloride but is precipi- 
tated by cocaine hydrochloride; this however may be pre- 
vented by the addition of boric acid solution (dissolve the 
cocaine in the boric acid solution and then mix this with 
the protargol solution). No glycerin should be used in 
making a solution of protargol as it renders the solution more 
irritating. 

As an injection protargol is used in the strength of Yio^o. 
to 1 per cent. ; as instillation in the strength of 1 to 10 



266 GONORRHEA AND ITS COMPLICATIONS 

per cent, and as an irrigation 1-50 to y 2 per cent. (1 :5000 
to 1:200). Protargol is one of our most valuable organic 
silver salts, and is so far the best substitute we have for 
silver nitrate. Unfortunately it is rather irritating in 
strong solutions, being in susceptible individuals as irritat- 
ing as silver nitrate itself. But if we adjust the strength 
to the acuteness of the symptoms, we can avoid too much 
irritation. Its field is acute and subacute gonorrhea. In 
chronic urethritis, gonorrheal or non-gonorrheal, it cannot 
take the place of silver nitrate. No other drug or chemi- 
cal can. 

Silvol. 

A new silver proteid compound, containing 20 per cent, 
of metallic silver. Claimed to be actively germicidal and 
may be used in 25 per cent, solutions. On the market in 
1 oz. bottles and in 6 gr. capsules in bottles of 50 capsules. 
The capsules are convenient to make extemporaneous solu- 
tions. 

Sophol 

A combination of silver with methylennucleinic acid 
containing 20 per cent, of silver. Yellowish powder, read- 
ily soluble in water. Used principally in the prophylaxis 
of ophthalmia neonatorum, in 5 per cent, solution. Non- 
irritating. Have used it a few times in gonorrhea in 2 per 
cent, solution, but am unable to make definite statements 
as to its value in comparison with other silver salts. Solu- 
tions should always be freshly prepared with cold water. 



CHAPTER XXXVII 

MISCELLANEOUS ANTISEPTICS AND 
ASTRINGENTS 

Potassii Permanganas. Potassium Permanganate 

KMn0 4 

Dark purple prisms or crystals. Soluble in 16 parts 
of water, decomposed by alcohol, glycerin and most organic 
substances, and is therefore preferably used by itself. The 
statement may sound strange to some, but potassium per- 
manganate is not used by me very frequently. As an in- 
jection of proper concentration (1:1000, or 1:500) it is too 
irritating. Its real value is in weak solutions, 1:3000 to 
1 :10000, and in large quantities as an irrigation. But as 
I do not use irrigations in the routine treatment of gon- 
orrhea, I do not often have occasion to use potassium per- 
manganate. 

The few drugs which I use in the local treatment of gon- 
orrhea are the following in the order named: (1) An 
organic silver salt (protargol + argyrol), for acute gon- 
orrhea, (2) silver nitrate for chronic gonorrhea, (3) po- 
tassium permanganate, as a change and in non-gonorrheal 
urethritis, (4) zinc sulphate or lead acetate (5) diluted 
tincture of iodine. 

Chinosol 

Chinosol is chemically oxyquinolin sulphate. A yellow 
crystalline powder of a peculiar aromatic odor and burning 

267 



268 GONORRHEA AND ITS COMPLICATIONS 

taste; very soluble in water, the solution having an acid 
reaction. This is a powerful antiseptic, stronger than mer- 
curic chloride and much stronger than carbolic acid. It 
exerts an antiseptic action even in solutions of 1 in 5000. 
Nevertheless it is absolutely non-toxic, which renders it 
very valuable in washing the bladder and irrigating the 
urethra. The strength of the solutions may vary from 1 
in 5000 to 1 in 1000. It has also a decided analgesic action, 
and in solutions of 1 in 8000 to 1 in 5000 may be used even 
in hyperacute (non-gonorrheal) urethritis. 

Thallini Sulphas. Thalline Sulphate 

Thalline sulphate is chemically tetrahydroparamethyl- 
oxyquinoline sulphate (thalline has nothing to do with 
the element thallium). "White powder soluble in water 
and in oil. Used in acute gonorrhea in 1 to 2 per cent, 
aqueous solutions, or in chronic gonorrhea in 5 per cent, 
oily solutions. This drug is Casper's favorite, and I gave 
it a pretty thorough trial, and while it is undoubtedly a 
useful agent, it has no special merits to entitle it to be used 
in the routine treatment of gonorrhea. It turns brown on 
exposure, and it and its solutions should therefore be kept 
in amber-colored bottles protected from light. 

IchthyoL Ammonium Ichthyol-sulphonate 

Obtained by the distillation of a bituminous shale found in 
Tyrol. A reddish brown thick syrupy liquid, peculiar odor 
and taste. Is not used much in gonorrhea, but it does occa- 
sionally give good results in obstinate gleet, in the form of 
a 2 per cent, injection. 



ANTISEPTICS AND ASTRINGENTS 269 

Hydrargyri Oxycyanidum. Mercury Oxycyanide 

Mercuric oxycyanide. HgO. HgCN 2 . A white crystal- 
line powder soluble in hot water. Claimed to be six times 
more active as a germicide than mercuric chloride. Used 
as a general antiseptic, as a preservative in lubricants, 
and to wash out bladder — for the latter purpose in 1 in 5000 
to 1 in 3000 strength. 

Alumen. Alum. Aluminium and Potassium Sulphate 

White powder, soluble in water and in glycerin. A pure 
astringent, used occasionally in chronic gonorrheal and in 
non-gonorrheal urethritis, in 1 to 5 per cent, strength. It 
is seldom prescribed alone, usually as one of the ingredients 
in astringent injections. Often prescribed with lead ace- 
tate (see lead acetate), when it produces a double decom- 
position with the formation of aluminium and potassium 
acetate (in solution) and lead sulphate (in precipitation), 
according to the following reaction : 

Al 2 K 2 (S0 4 ) 4 + 4 Pb(C 2 H 3 2 ) 2 = 2 A1(C 2 H 3 2 ) 3 + 
2 KC 2 H 3 2 + 4 PbS0 4 . 

3J Plumbi Acetatis, gr. viij 
Aluminis, gr. viij 
Aquae, % iv 
Sig. Shake well. 

A dram of powdered acacia may be added to the above 
prescription to keep the lead sulphate better in suspension. 

Cupri Sulphas. Copper Sulphate 

Large deep blue crystals. Very soluble in water and 
in glycerin. Powerful astringent. Seldom used in gon- 



270 GONORRHEA AND ITS COMPLICATIONS 

orrhea of the male, though occasionally it renders excellent 
service in chronic, dragging cases. It is then nsed as an 
injection, Y 10 to 1 per cent, strength (y 2 gr. to 5 grains 
to the ounce), or as an instillation, 1 to 10 per cent, strength, 
2 to 3 drops. The solution may be made with water alone, 
or with water and glycerin. For instillation, I use a 5 or 
10 per cent, solution in pure glycerin (no water at all be- 
ing employed) ; the crystals are crushed, put into the gly- 
cerin, and the bottle is placed in a dish with warm water, 
and shaken occasionally until dis'solved. In female gon- 
orrhea, it is used with good results, combining cheapness 
with good astringent and bactericidal properties. In the 
division of the Vienna General Hospital, where the prosti- 
tutes are treated, gallons and gallons of copper sulphate 
solution are used daily. 

Plumbi Acetas. Lead Acetate. Sugar of Lead 

Colorless crystals or whitish powder, very soluble in water 
and in glycerin. Efflorescent and readily attracts car- 
bon dioxide from the air, becoming converted into lead car- 
bonate. Should therefore be kept in well stoppered bottles. 
Pure astringent, used in strength of % to 2 per cent. (1 to 
10 grains to the ounce of water) . Is frequently prescribed 
in combination with zinc sulphate, when a chemical decom- 
position takes place, zinc acetate being formed and remain- 
ing in solution, and lead sulphate precipitating. The reac- 
tion is as follows: 

ZnS0 4 + Pb(C 2 H 3 2 ) 2 ==Zn(C 2 H 3 2 ) 2 + PbS0 4 . 

To be properly prepared, the zinc sulphate and the lead 
acetate are to be dissolved separately each in about half of 



ANTISEPTICS AND ASTRINGENTS 271 

the water prescribed, then one solution is to be added 
slowly and in small portions to the other, shaking after each 
addition. Prepared this way the lead sulphate is in very 
fine subdivision, and not in lumps, and when injected it 
does not irritate the urethra, but leaves a fine coating over 
it, which produces a prolonged astringent and healing ac- 
tion. A good formula is the following : 

Zinci sulphatis, gr. xij 
Plumbi acetatis, gr. xij 
Hydrastis aquos., fl. § ss 
Acaciae pulv., 3 iss 
Aquae q. s. ad. § iv 
S. Shake well. 

Zinci Acetas. Zinc Acetate 

Soft white crystals of a pearly luster. Very soluble in 
water (in about 2y 2 parts). Purely astringent. Used as 
a urethral injection in strengths of % to 3 per cent. Often 
less irritating than zinc sulphate. 

Zinc chloride and zinc iodide are merely mentioned to be 
condemned. They have no field in any form of urethritis. 

Zinci Sulphas. Zinc Sulphate 

Colorless crystals or a crystalline powder, very soluble 
in water (about half a part) and in glycerin (3 parts). 
Its field is in the terminal stages of gonorrhea, though by 
its astringent action it sometimes does good service in the 
first stage also, when the discharge is very profuse, and 
the other symptoms not very acute. Used as an injection 
in strength of % to 3 per cent. In the office best kept as a 



272 GONORRHEA AND ITS COMPLICATIONS 

10 per cent, solution, with a little boric acid to prevent 
fungous growths. 

Of late, I have been in the habit of adding a little zinc 
sulphate to my silver nitrate injections and instillations. 
While not interfering with the specific action of the silver, it 
does counteract the tendency of the latter to cause or in- 
crease discharge. 

Zinci Permanganas. Zinc Permanganate 

Violet brown crystals, very hygroscopic, very soluble in 
water. As an injection y 10 to y 2 per cent solution (1% to 
2% grains to the ounce) . Sometimes very serviceable in old 
gleety conditions. Should not be rubbed or brought in con- 
tact with organic substances (like glycerin) or explosion 
may o$eur. 

Nizin 

Nizin is chemically zinc sulphanilate. On the market in 
the form of 2 grain tablets, of which one to three to the 
ounce of water is used as a urethral injection. 



CHAPTER XXXVIII 

VEGETABLE ASTRINGENTS 

Numerous vegetable astringents have been used in the 
treatment of gonorrhea within the last century or two. To 
enumerate them would mean to enumerate all drugs con- 
taining an astringent principle, such as nutgalls, oakbark, 
catechu, krameria, matico, tannic acid, gallic acid, etc., etc. 
They have all fallen practically into disuse, because they are 
7 not uniform in their composition, uncertain and unreliable 
in their action, possess no antiseptic properties and cannot 
be made sterile. For these reasons they have very prop- 
erly been discarded. The only vegetable drug that is still 
used rather frequently in urethral injections, is hydrastis, 
and this drug is not used on account of its purely astringent 
action, but it is supposed to exert a specific action in con- 
trolling the hyperemia of the urethral canal. It is not on 
account of its tannic acid that we use it, but on account of 
its valuable alkaloids hydrastine, and to a lesser extent ber- 
berine. Formulas containing hydrastis will be found in the 
Formulary, at the end of the volume. 

Lloyd's aqueous hydrastis is used considerably, and a so- 
lution of the alkaloids hydrastine and'hydrastinine gives 
good results occasionally. 



273 



CHAPTER XXXIX 
LOCAL ANESTHETICS 

Cocaine Hydrochloride 

Cocaine is the chief alkaloid of coca leaves. Medicinally 
it is used principally in the form of the hydrochloride. It 
is in the form of small or large colorless crystals, granular 
or fine white powder. It is exceedingly soluble in water 
(less than half a part, that is 10 grains of the salts require 
only 4 drops or minims of water for complete solution). 
It was the first local anesthetic discovered (by Dr. Carl 
Koller, in 1884), and it still remains our surest, promptest 
and longest lasting agent for producing local anesthesia. 
It also has the great advantage of contracting the blood 
vessels of the part to which it is applied, producing a local 
ischemia, thus rendering operations more or less bloodless. 
It would be the ideal local anesthetic, but for one thing: 
it is very toxic, unexpected dangerous by-effects, collapse, 
etc., are produced by its use, and it has been responsible 
for a number of deaths. Its toxicity has led the world's 
great chemists to invent synthetic substitutes, and they have 
been quite successful. Several are now in general use, 
but for genito-urinary manipulations only three come under 
consideration. They are: Alypin, beta-eucain and novo- 
caine. 

Alypin. Alypin Hydrochloride 
Alypin is chemically the hydrochloride of benzoyl tetra- 
methyl (diamine) ethylisopropyl alcohol. It is a white 

274 



LOCAL ANESTHETICS 275 

crystalline powder readily soluble in water, and quickly ab- 
sorbed by mucous membranes. It is one of the best, if not 
on the whole the best, local anesthetic in genito-urinary 
diseases, because it is practically equal in its effects to co- 
caine, but is much less toxic. Used in same strength as 
cocaine, generally 2 to 4 per cent, solutions. As it pro- 
duces a transient hyperemia, it is best, in cutting operations, 
to combine it with suprarenal preparations. Alypin may 
be sterilized by boiling, but it is best to proceed as follows : 
First boil the water thoroughly, say in a test tube, then add 
the alypin, and continue the boiling for another minute over 
a small flame. 

Alypin nitrate. As alypin, which is a hydrochloride, 
is incompatible with silver nitrate, we must use a nitrate 
whenever we wish to combine alypin with silver nitrate, or 
when we wish to anesthetize the urethra prior to the use of 
silver nitrate. The properties of alypin nitrate are practi- 
cally the same as those of alypin. 

Eucaine. Beta-eucaine 

This synthetic local anesthetic is on the market in two 
forms, the hydrochloride and the lactate. Chemically eu- 
caine is trimethylbenzoxypiperidin. The hydrochloride is 
a white powder, soluble in about 25 parts of water, 
producing a neutral solution, which can be boiled without 
decomposition. As a local anesthetic it is weaker, but less 
toxic than cocaine, nor does it produce the ischemia which 
the latter does. May be used in 2 to 4 per cent, solutions. 

Beta-Eucaine Lactate. Properties the same as of the 
hydrochloride, but is more soluble in water. 



276 GONORRHEA AND ITS COMPLICATIONS 

Novocaine. Novocaine Hydrochloride 

Novocaine is chemically the hydrochloride of para-amino- 
benzoyldiethylaminoethanol. Small colorless crystals, very 
soluble in water (1 part), and the solution may be heated 
to boiling without decomposition. An efficient local anes- 
thetic, but much less toxic than cocaine. For anesthesia 
in the urethra 1 to 4 per cent, solution may be used. Its 
effect is more satisfactory if combined with a few drops of 
epinephrin or adrenalin solution. There are on the market 
tablets containing both novocaine and adrenalin or supra- 
renale. 

Novocaine nitrate. As novocaine hydrochloride gives a 
precipitate with silver nitrate, we must use novocaine 
nitrate whenever we wish to combine the two (See Alypin 
Nitrate) . 

There is also a novocaine base, which is soluble in oils. 



CHAPTER XL 

ANTIGONORRHEAL REMEDIES FOR INTERNAL 

USE 

Oil of Santalwood, Its Derivatives and Combinations 

The principal remedies used internally in the treat- 
ment of gonorrhea are the so-called Balsamics. They com- 
prise (1) oil of santalwood and its numerous derivatives 
and combinations, (2) copaiba and (3) cubebs. 

Oleum Santali. Santalwood Oil. East Indian Sandal- 
wood Oil. Oil of White or Yellow Sandalwood 

A volatile oil obtained by distilling the wood of Santalum 
Album. Yellowish somewhat thick liquid, with a peculiar 
aromatic odor and disagreeable taste. Its virtues depend 
upon its active principle, santalol, of which it should contain 
not less than 90 per cent. The dose is 5 to 10 minims, pref- 
erably in capsules, 3 or 4 times a day, about an hour after 
meals. 

Oil of santal is a very valuable remedy in gonorrhea ; un- 
fortunately we are frequently disappointed in its action, 
because much of the santal oil of the market is adulterated 
with the West Indian oil, with castor oil, oil of turpentine, 
etc. Some of the santal oil dispensed in drug stores is 
practically worthless. It is therefore important to order 
the oil in capsule form, specifying the brand of certain re- 
liable- manufacturers. 

277 



278 GONORRHEA AND ITS COMPLICATIONS 

I start with the santal oil quite early in the disease — 
three to five days after the discharge has been well estab- 
lished. For the first few days I give an alkaline anti- 
spasmodic mixture, and then as the acute symptoms have 
somewhat subsided, I start in with santal oil (see chapter 
on the treatment of acute gonorrhea) and keep it up, 
more or less, during the entire course of the disease. I find 
that it shortens the disease, prevents complications and 
makes the local treatment easier to manage; that is, the 
injections cause less irritation than they do without the use 
of the balsamics. 

Santal wood oil is a most valuable drug ; unfortunately it 
has two disagreeable by-effects. They do not manifest them- 
selves in all patients, but they do in a considerable pro- 
portion. These by-effects are: gastric irritation, which 
expresses itself in loss of appetite, belching, heartburn, etc., 
and in irritation of the kidneys, which shows itself by 
pain, sometimes quite severe, across the lumbar region, 
and by a slight albuminuria. These disagreeable by-effects 
led the manufacturing chemists to improve the santal wood 
oil, by isolating its active principle, santalol, and combin- 
ing it chemically in such a manner as to make it insoluble 
in the stomach; the preparation splitting up and being 
absorbed in the intestines only. These improvements 
on santal wood oil are very valuable, only they are more 
expensive. Still in delicate patients and in patients who, 
on account of gastric or renal disturbance, cannot tolerate 
the pure santal wood oil, we are obliged to administer its 
various derivatives and combinations. 



INTERNAL REMEDIES 279 

Allosan 
This is chemically the allophanic acid ester of santalol, 
containing 72 per cent, of the latter. Doses and uses 
same as of oil of sandal wood. 

Arheol 

Arheol is pure santalol, the active principle of oil of 
sandalwood. Dose 9 to 12 capsules daily. 

Blenal 

Blenal is chemically santalol carbonate, or the carbonic 
acid ester of santalol. It is odorless, tasteless, and claimed 
to be absolutely nonirritating to stomach or intestines. 
Dose : 15 drops 3 times a day, on sugar or in hot milk. 

Carbosant 

Carbosant is santalol carbonate, the same as Blenal, 
which see. 

Gonosan. Gonosan Capsules. Kava-Santal 

Gonosan is a solution of the resins of kava-kava in pure 
sandalwood oil. On the market in the form of capsules 
only, the dose of which is one to two capsules three to four 
times a day. It is one of the most valuable combinations 
we have in the internal treatment of gonorrhea, because the 
kava-kava has a distinct analgesic effect, and the combina- 
tion as a rule promptly subdues the pain of urination, 
strangury, etc. It also seems to reduce the secretion more 
promptly than sandalwood oil alone. 

Santyl. Santalol Salicylate 

Santyl is chemically salicylate of santalyl. It contains 
approximately 60 per cent, of santalol and 40 per cent, of 



280 GONORRHEA AND ITS COMPLICATIONS 

salicylic acid. Yellowish oily liquid with slight odor and 
taste. Passes the stomach for the most part unchanged, 
splitting up into its two constituents in the intestines. It 
is remarkably free from any irritating effects on the stomach 
and kidneys, though occasionally we of course meet a man 
or a woman who complains of eructations. It is very rare 
however to find a patient in whom it causes even transient 
albuminuria or pain across the kidneys unless it is given in 
very large doses. On the market in liquid form and in 
capsules, containing 8 minims (0.5) each. Dose, 2 cap- 
sules 4 times a day or 3 capsules 3 times a day. 

Thyresol 

Thyresol is chemically the methyl ether of santalol. It is 
a colorless liquid, of an aromatic odor, insoluble in water, 
and it is claimed to pass the stomach unchanged, liberating 
the santalol only in the intestines, thus saving the patient 
from eructations and other gastric disturbances. On the 
market in liquid form, in 5 grain capsules and in 5 grain 
tablets (prepared with magnesium carbonate). Dose: two 
capsules or tablets 3 or 4 times a day. 

Copaiba 

This popular remedy incorrectly referred to as Balsam 
of Copaiba is an oleoresin (that is, it consists of an oil and 
a resin) obtained from several South American species of 
copaiba. It is a thick viscid liquid, yellow to brownish 
yellow in color, having a peculiar, rather disagreeable 
aromatic odor and a disagreeable acrid taste. Insoluble in 
water, but soluble in fixed and volatile oils. This is one of 
the best known and most popular antigonorrheics, but also 



INTERNAL REMEDIES 281 

one of the nastiest and most nauseating. But few people 
can stand it without having their stomach upset or their 
kidneys irritated. It is well to bear in mind that if nitric 
acid be added to the urine of a person taking copaiba, a 
precipitate will be formed, which may make the unwary 
physician believe that the patient has albumen in his urine. 

The dose of copaiba is 10 to 30 min. 3 to 4 times a day. If 
given at all it should be given in capsules. To give it on 
sugar, in water or even in emulsion is to inflict unnecessary 
cruelty on the patient. 

It is the chief ingredient in the famous (or infamous) 
Lafayette mixture (mistura copaiba, Lafayette, N. F.), 
which consists of copaiba, spirit of nitrous ether, compound 
tincture of lavender, solution of potassium hydroxide, syrup 
and mucilage of acacia. (For complete formula see For- 
mulary.) 

Oleum Copaibae 

Copaiba can be separated into the two constituents: an 
oil and a resin. The resin is almost inert and is no longer 
official. The oil is official, and may be given in doses of 10 
to 30 minims. 

Cubeba 

Cubeb is the fruit (unripe but full grown) of Piper 
Cubeba. It is occasionally used in substance, in the form 
of powder, but more commonly in the form of one of its 
derivatives, the oleoresin or the oil. The fluid extract is 
not a good preparation, because it contains alcohol, and we 
do not wish to give alcohol in gonorrhea. The dose of pow- 
dered cubebs is 10 to 60 grains in capsule, cachet or paste 



282 GONORRHEA AND ITS COMPLICATIONS 

form ; the dose of the oleoresin is 10 to 20 minims ; of the 
oil 10 to 30 minims. If at all administered, it should be 
given only after the acute inflammatory symptoms have 
subsided. 

Copaiba and cubebs are seldom prescribed by venereal 
specialists, and still more seldom prescribed alone. As a 
rule we give a combination, in capsule form, of copaiba, 
oleoresin of cubeb and oil of sandalwood. A small quan- 
tity of some pleasant volatile oil, such as oil of cinnamon or 
cardamom is also added to make the combination less unac- 
ceptable to the stomach. If we could have capsules insol- 
uble in the stomach, but soluble in the duodenum, quite an 
advance would be made in the treatment of our gonorrheal 
patients. So many stomachs would be saved from unnec- 
essary torture. But unfortunately we are still far from 
possessing a really stomach-insoluble but intestine-soluble 
capsule. 

Arhovin 

A compound or mixture of diphenylamine, thymol ben- 
zoate and ethyl benzoate. Offered as a substitute for the 
santal oil preparations. Generally prescribed in capsules 
of 4 minims each — one to two capsules three to six times 
a day. 



CHAPTER XLI 
URINARY ANTISEPTICS 

Hexamethylenamine 

This product is obtained by the action of ammonia on 
formaldehyde. Chemically it is hexamethylene tetramine 
(CH 2 ) 6 N 4 , and is known to commerce under a great vari- 
ety of trade names. Urotropin, under which name it was 
originally introduced to the medical profession, is sup- 
posed to be the purest brand; other names by which it 
is known are: formin, cystogen, aminOform, uritone, etc. 
On excretion from the kidneys, it decomposes with the 
liberation of a small percentage of formaldehyde, but it 
does this only in acid urine. When administering hexa- 
methylenamine we must therefore make sure that the urine 
is acid; and if it is not, we must render it acid by the 
administration of monosodic acid phosphate or similar sub- 
stances. While the action of hexamethylenamine in clear- 
ing up a bacterial urine, in cystitis, pyelitis, etc., is un- 
questionable, it is of no value in gonorrhea, and its admin- 
istration without any definite indication is not only use- 
less, but often proves injurious by its irritating effect on 
the neck of the bladder. There is no question that some 
brands of hexamethylenamine on the market are more irri- 
tating than others, and if given in large doses, not properly 

diluted, hematuria may result. 

283 



284 GONORRHEA AND ITS COMPLICATIONS 

The dose of hexamethylenamine is 5 to 15 grains dis- 
solved in 8 to 12 ounces of water 3 to 4 times a day. Un- 
fortunately some doctors are careless in this respect, and 
we have seen patients with gastro-intestinal, renal and 
vesical irritation from swallowing the tablets whole, with- 
out previous solution in water. 

The best way is to order 5 or 7% grains of hexamethy- 
lenamine with 10 grain tablets of monosodic acid phosphate 
and order one tablet of the former with one or two tablets 
of the latter to be dissolved in a large glass of water. Tab- 
lets are now manufactured containing both chemicals. 

I wish to emphasize that in uncomplicated gonorrhea 
hexamethylenamine has no place. Wherever any instru- 
mentation becomes necessary, such as irrigating the bladder, 
passing a sound, etc., then it becomes invaluable in pre- 
venting infection. In such cases it is advisable to have 
the patient take a dose when he leaves for the office, and 
another dose when he gets home. 

Amphotropin 

This recent addition to the list of urinary antiseptics is 
chemically Hexamethylenamin Camphorate. It is a white 
crystalline powder soluble in about 10 parts of water. It 
renders alkaline urine acid, and has a diuretic action. 
Claimed to be specially indicated in bacteriuria, chronic 
cystitis and pyelitis, Contraindicated in acute cystitis and 
urethritis. Dose 7% to 15 grains (one to two tablets) 
3 times a day, dissolved in water. 

Aminoform 
This is a trade name for hexamethylenamine. 



URINARY ANTISEPTICS 285 

Borovertin 

Borovertin is chemically hexamethylenamin borate, con- 
sisting of about equal parts of hexam. and boric acid. 
White powder soluble in 11-12 parts of water. Dose 8 to 
15 grs. 3 times a day. 

Cystogen 
This is a trade name for hexamethylenamine, which see. 

Helmitol 

Helmitol is chemically hexamethylenamin-anhydro- 
methylencitrate. White powder, slight acid taste, soluble 
in 10 parts of water. Same action as hexamethylenamin, 
but it is claimed that it is active in alkaline as well as in 
acid urine. Dose: 5 to 15 grains (1 to 3 tablets), dis- 
solved in water 3 to 4 times a day. 

Hexalet, Hexal 

This is a chemical combination of hexamethylenetetramine 
(40 per cent.) and sulphosalicylic acid (60 per cent.) It 
is in the form of small white crystals very soluble in water, 
of an acidulous taste. Claimed to possess decided advan- 
tages over hexamethylenamine. Dose: 15 grains dissolved 
in a glass of water 3 to 4 times a day. 

Urotropin 
The purest brand of hexamethylenamine on the market. 

Saliformin 

Saliformin is hexamethylenamin salicylate. White 
powder, slightly acid taste, readily soluble in water. 
Claimed to possess the combined actions of its two con- 



286 GONORRHEA AND ITS COMPLICATIONS 

stituents, hexamethylenamin and salicylic acid. Dose : 5 to 
15 grains 3 to 4 times a day. 

Sodium Acid Phosphate, Monobasic 

When the urine is alkaline, and full of bacteria, it is 
often necessary quickly to acidify it, in order to permit 
urotropin or hexamethylenamin to exert its action, the 
latter drug as mentioned elsewhere not acting in an alkaline 
medium. For this purpose of acidifying the urine, one of 
the best agents is the recently introduced monosodic acid 
phosphate. This is administered in doses of 15 to 30 
grains frequently repeated until the desired effect is ob- 
tained. The ordinary sodium phosphate of the market, used 
as a cholagogue and laxative, is also an acid phosphate, 
but that contains two atoms of sodium and one atom of 
hydrogen, in other words it is dibasic; while this salt con- 
tains only one atom of sodium and two atoms of hydrogen : 
it is therefore called monobasic sodium acid phosphate, 
or monosodic acid phosphate. You should be careful in 
ordering to specify: monosodic or monobasic, or you will 
surely get the common sodium phosphate. 

Methylene Blue 

Methylene Blue is chemically Tetramethylthionine 
hydrochloride. It is one of the numberless anilin dye- 
stuffs, but purified. It is a dark green crystalline powder, 
very soluble in water, and it renders everything it touches 
intensely blue. It is a nuisance to handle it, and is best 
administered in the ready combinations, in pill or capsule 
form. The dose is 2 to 4 grains, with a small dose of nut- 
meg and extract of belladonna. The patient must be 



URINARY ANTISEPTICS 287 

warned that his urine will become intensely green or blue. 
If not warned, he may get frightened out of his wits when 
noticing his urine for the first time, with the result that 
the doctor may have to answer to a violent bell or frantic 
telephone ring in the middle of the night. 

In pure uncomplicated gonorrhea, methylene blue seems 
to possess little if any value. In cases of mixed infection, 
however — and almost every case of chronic protracted gon- 
orrhea becomes sooner or later one of mixed infection — the 
drug seems to be a useful adjuvant. In impatient patients, 
in patients of the nervous, neurasthenic stamp, who want to 
see that something is being done for them, methylene blue 
is a welcome addition to our other remedies. 



CHAPTEE XLII 
LUBRICANTS 

A lubricant (from Latin lubricus, slippery) is a sub- 
stance used to diminish friction and adhesion, to render 
another substance slippery and easy of passage. In pass- 
ing catheters, bougies, sounds, urethroscopes, cystoscopes, 
etc., we must use a lubricant, as otherwise the instrument 
would not pass at all, or would pass only with difficulty 
and with damage to the mucous membrane. There are 
many formulas for lubricants and there are many artificial 
water-soluble lubricants on the market, but even the best 
of them do not possess the same amount of lubricity that 
is possessed by the fats and oils, such as petrolatum, par- 
affin or olive oil, for instance. And in attempting to pass 
a sound through a narrow, tortuous or even spasmodic 
stricture nothing will answer the purpose as well as filling 
the urethra with sterilized olive oil. 

Nevertheless we are obliged to use water-soluble lubri- 
cants, and for these reasons. We often have to follow our 
dilatation by sounds, bougies or dilators with silver nitrate 
solution, or with a solution of some other chemical in water. 
If we use an oily or fatty lubricant it coats the urethra 
with a layer of oil or fat, so that the watery solution can- 
not reach it properly and exert its proper effect. Then it 
is much more difficult to sterilize instruments on which an 
oily lubricant has been used. And last, rubber goods are 

288 



LUBRICANTS 



289 



injuriously affected by oils and fats. For these reasons 
substitutes for the natural lubricants are in common use, 
but I repeat the best of them are not fully satisfactory, 
and personally I still use occasionally sterilized and sali- 
cylated oil for the urethra and petrolatum for the rectum. 
Glycerin is not very satisfactory, because it does not 





Containers for Lubricants 

possess sufficient lubricity, in cold weather it is thick and 
sticks, and it often causes burning and irritation in the 
urethra. 

The artificial lubricants generally have chondrus (Irish 
moss) and glycerin or tragacanth for a base. One of the 
best formulas is the one originally proposed by Casper. It 
has the following composition: 

Hydrargyri oxycyanidi, 0.246 
Tragacanthae, 3.0 
Glycerini, 20.0 
Aquae destill. steril., 100.0 

Some hypersensitive urethras feel some irritation from 
the use of this lubricant. It is also a little too thick, par- 
ticularly in cold weather. I have therefore modified the 



290 GONORRHEA AND ITS COMPLICATIONS 

formula, and this yields me a more satisfactory product. 
My modified formula is as follows: 

Hydrargyri oxycyanidi, 0.2 (3 grains) 
Tragacanthae, 2.0 (30 grains) 
Glycerini, 20.0 (5 drams) 
Aquae destill. steriliz., 120.0 (4 ozs.) 

Keep well covered in small, wide mouthed bottles, or 
have it filled in tin tubes. 

Of the ready-made lubricants on the market, K-Y jelly 
is the best known and the one generally preferred. Others 
are lubrichondrin, lubraseptic, etc. 

The ready-made lubricants come in collapsible tin tubes, 
a little being squeezed out each time as needed, the screw 
cap being kept on in the meantime. This prevents the 
contents from becoming contaminated. The lubricant or- 
dered from the druggist or prepared by the physician is 
kept in wide-mouth, well corked or stoppered bottles. 
Better however are the lubricant containers presented in the 
accompanying illustrations. The proper amount of lubri- 
cant is easily poured out when wanted, the opening in the 
meantime being protected by corks or cotton stoppers. 
One container can be used for the water-soluble lubricant, 
another one for sterile oil, plain or salicylated. 

If Ac. salicylici, gr. x 
Olei olivae, § iv 

Heat on a water bath to 100° C. for fifteen minutes, dis- 
solve the salicylic acid, cool, strain, heat again for five 
minutes and pour in sterilized bottle or container. 



FORMULARY. 

PRESCRIPTIONS FOR ACUTE AND CHRONIC GONORRHEA 
LAFAYETTE MIXTURE 

^ Copaibae gj [30.0] 

Liq. potassii hydrox 3ij [8.0] 

Spir. aetheris nitrosi §j [30.0] 

Ext. glycyrrhizae §ss [15.0] 

Syr. acaciae §iv [120.0] 

S. 3ij — §ss 3 times a day. 

This nauseous mixture may be made a little less nauseous 
by flavoring it with a few drops of oil of wintergreen or oil 
of cinnamon. 

MISTURA CAPAIBAE, LAFAYETTE, N. E. 

The National Formulary gives a somewhat different for- 
mula for Lafayette mixture. It is as follows : 

^ Copaibae gj [30.0] 

Liq. potassii hydrox 3ij [8.0] 

Spir. aetheris nitrosi §j [30.0] 

Tine, lavandulae comp gj [30.0] 

Syrupi (U. S. P.) gijss [75.0] 

Mucil. acaciae q.s. ad gviij [240.0] 

S. 3jj — §ss 3 times a day. 

291 



292 GONORRHEA AND ITS COMPLICATIONS 

chapman's copaiba mixture 

Copaibae gj [30.0] 

Spir. aetheris nitrosi gj [30.0] 

Tine, lavand. comp 3ij [8.0] 

Tine, opii 3j [4.0] 

Muc. acaciae gss [15.0] 

Aquae q.s. ad §iv [120.0] 

S. oj — 3ij t. i. d. 3 to 4 times a day. 

IJ Potassii citratis 3ij [8.0] 

Potassii bromidi 3ij [8.0] 

Liquor potassii hydroxidi 3i [4.0] 

Ext. hyoscyami fl 3i [4.0] 

Ext. tritici fl 3vi [24.0] 

Aquae, q.s. ad §vi [180.0] 

Sig. Tablespoonful three or four times a day in, or fol- 
lowed by, half a glass of water. 

^ Hexamethylenaminae gr. v [0.3] 

Sodii benzoatis gr. x [0.6] 

M.f. pulv No. i 

Tales doses No. xij 

S. One powder in a glass of water three to four times a 
day. 

If Hexamethylenaminae gr. vij ss [0.5] 

Sodii (mono) acidi phosphatis gr. xv [1.0] 

M.f. tabella No. i 

Tales doses No. xxx 

S. One in a glass of water three to four times a day. 



FORMULARY 293 

^ Methyllthioninae hydrochlor gr. ij [0.12] 

Phenyl salicylates gr. iij [0.18] 

Extr. belladonnae gr. % [0.01] 

Pulv. cinnamomi gr. ss [0.03] 

M.f . capsula No. i 

Tales doses No. xxx 

S. One capsule three to four times a day. 

^ Methylthioninae hydrochl. (methylene blue) 

K [4.0] 

Phenyl salicyl. (salol) 3iij [12.0] 

01. santali 3v [20.0] 

Oleores. cubebae 3v [20.0] 

Pancreatini 3i [4.0] 

Ol. cinnamomi gr. vi [0.3] 

Div. in caps, gelat. no. lx. 
One or two capsules two hours after each meal. 

I. FORMULAS OF CLEANSING INJECTIONS 

^ Sodii bicarbonatis gr. cl [10.0] 

Aquae destill. steriliz Oj [500.0] 

Mix with equal volume of hot water and inject two or 
three syringefuls every hour or two. (If you cannot do it 
so often, do it as often as you can.) 

T$ Sodii boratis gr. cl [10.0] 

Aquae destill. steriliz Oj [500.0] 

Directions same as with injection No. 1. 

^ Sodii chloridi c. p gr. xxx [2.0] 

Aquae destill. steriliz Oij [1000.0] 

Directions same as with No. 1. 



294 GONORRHEA AND ITS COMPLICATIONS 

n. FORMULAS FOR GONOCIDE SOLUTIONS 

^ Protargol gr. viij [0.5] 

Aquae destill gvijss [200.0] 

M. ft. solutio lege artis. Detur in vitro nigro. 
Sig. Use one syringeful at a time (two to four drams, 
depending on the capacity of the man's anterior urethra), 
and hold in five to ten minutes. - 

You must be sure that the solution of protargol is prop- 
erly prepared. Improperly prepared it contains lumps and 
will prove irritating. The best way to make a solution of 
protargol is to pour the water into a wide graduate or a 
mortar, and then throw, with a sifting motion, the protargol 
on the water ; it is light and floats. Leave it without shaking 
or stirring; in a few minutes it will be found to have be- 
came dissolved. As seen, I commence with a % per cent, 
solution (1 :400). The amount may be raised to one or two 
per cent., but I seldom go beyond one per cent. 

Protargol should not be prescribed with zinc sulphate : the 
two are incompatible. 

^ Argyrol 3ijss— 3v— Sxijss [10.0—20.0—50.0] 

Aquae destill gviij [240.0] 

Use the same way as the protargol solution. 

^ Protargol gr. viii [0.5] 

Argyrol 3ijss [10.0] 

Aquae destill gvij [200.0] 

Sig. Use one syringeful 3 to 4 times a day. 

The combination of the two silver salts, original with the 
author, often gives very happy results. Argyrol alone is 



FORMULARY 295 

often too mild and inefficient, protargol is sometimes too 
irritating, but the combination is both efficient and sooth- 
ing. I could find no incompatibility between the two chem- 
icals. 

IJ Thalline sulph gr. xv [1.0] 

Aquae destill gvij [200.0] 

This is a V2 P er cent, solution ; the strength may be raised 
to 2 per cent., but 1 per cent, is generally the most satisfac- 
tory. 

^ Ichthyol 3i— 3jss [4.0 to 6.0] 

Aquae destill gviij [240.0] 

This is used in "dragging" cases and is good as an al- 
ternate injection. 

III. FORMULAS FOR ASTRINGENT INJECTIONS 

IJ Zinci sulphatis gr. viij [0.5] 

Aquae destill giv [120.0] 

Inject three or four times a day. 

^ Zinci sulphatis gr. viij [0.5] 

Plumbi acetatis gr. viij [0.5] 

Aquae destill giv [120.0] 

Shake well. Inject three or four times a day. 

^ Zinci sulphocarbolatis gr. xvj [1.0] 

Aquae destill giv [120.0] 

^ Zinci sulphatis. 

Plumbi acetatis, , aa gr. viij [0.5] 

Tr. opii 3j [4.0] 



296 GONORRHEA AND ITS COMPLICATIONS 

Tr. catechu 3ij [8.0] 

Aquae ad giv [120.0] 

The following, however, is my favorite : 

IJ Zinci sulphatis gr. viij [0.5] 

Bismuthi subearbon (vel. subnitr.) . . . 3iij [12.0] 

Bismuthi subgall 3j [4.0] 

Hydrastis aquos gj [30.0] 

Pulv. acaciae, 3jss [6.0] 

Aquae ad giv [120.0] 

M. f. mistura lege artis. 

Keep bottle flat and shake well before using. 

[If prepared by a competent pharmacist this prescription 
makes a smooth homogeneous mixture, like an emulsion. 
Prepared by an incompetent pharmacist, it is lumpy, gritty, 
and often proves irritating to the urethra.] 

This leaves a protecting coating over the urethral canal, 
exerting a soothing and healing influence. The coating re- 
mains in the urethra until the next urination. This in- 
jection finishes up the treatment. 

Ultzmann's Injection: 

Zinci sulphatis gr. viij [0.5] 

Aluminis gr. viij [0.5] 

Ac. carbolici gr. iv [0.25] 

Aquae giv [120.0] 

Injection in non-gonorrheal urethritis: 

I£ Ac. carbolici (phenol) gr. xij [0.8] 

Zinci sulphatis gr. xx [1.3] 

Aluminis gr. xxx [2.0] 

Aquae gviij [250.0] 



FORMULARY 297 

S. Inject 3 to 4 times a day, holding in the injection 3 
to 5 minutes. 

Europhen 3i [4.0] 

01. amygd. express §j [30.0] 

S. gtt. V-X in the posterior urethra, in chronic posterior 
urethritis and prostatitis. 

Thymol iodide 5i [4.0] 

01. amygd. express gj [30.0] 

S. Use same as previous prescription. Both prescrip- 
tions may be made a little weaker, using 1 part of the drug 
in 10 parts of almond oil or olive oil. 

Europhen 3ss [2.0] 

Thymol iodide 3ss [2.0] 

Vaselini liquidi albi 3x [40.0] 

S. gtt. V-X in the posterior urethra daily or every other 
day, in obstinate chronic posterior and anterior urethritis. 
Useful also after dilatation of strictures, as it probably helps 
somewhat in their absorption. 

3J Zinci sulphatis gr. xv [1.0] 

Plumbi acetatis gr. xv [1.0] 

Extr. krameriae fl 3iij [12.0] 

Tine, opii 3ij [8.0] 

Aquae destill. q.s. ad gvi [180.0] 

S. Inject 3 to 4 times a day. An old fashioned prescrip- 
tion, but quite useful in gleet. 

IJ Zinci permanganatis gr. iij 

Aquae destill Jvi 

S. Inject 3 to 6 times daily. 



298 GONORRHEA AND ITS COMPLICATIONS 

FOR BALANITIS: 

If Zinci oxidi 3i [4.0] 

Bism. subnitratis 3i [4.0] 

Ac. salicylici gr. v [0.3] 

Petrolati albi SJ [30.0] 

ty Perhydrol (100 vol. Hydrogen dioxide), §j [30.0] 
S. Touch up any erosions with a small cotton swab 
dipped in perhydrol and then wash with ordinary hydrogen 
dioxide. (In erosive balanitis.) 

FOR ADENITIS OR BUBO: 

^ Ung. hydrargyri 3ij [8.0] 

Guaiacoli 3i [4.0] 

Ung. belladonnae Si [30.0] 

If Plumbi Iodidi 3i [4.0] 

Ung. Potassii Iodidi gi [30.0] 

IJ Ung. hydrargyri 3ij [8.0] 

Guaiacol 3ss [2.0] 

Adipis 3vi [24.0] 

M. ft. unguentum 

Sig. Apply three times a day covering with gauze. 

ACUTE PROSTATITIS 

^ Morphinae sulphatis gr. % [0.02] 

Ext. belladonnae gr. % [0.02] 

01. theobromae gr. xx [1.3] 

For one suppository. Tal. dos. xij. 
S. One 3 times a day. 



FORMULARY 299 

IJ Iodoformi gr. ij [0.12] 

Antipyrini gr. v [0.3] 

Morphinae sulphatis gr. % [0.015] 

01. theobromae gr. xxv [1.5] 

Sig. One 3 times a day. 

CHRONIC PROSTATITIS 

^ Iodoformi gr. i [0.06] 

Morph. sulph gr. % [0.015] 

01. theobromae gr. xxv [1.5] 

M.f. supp. No. 1. Tal. dos. xij. 
Sig. One t. i. d. 

^ Potassii iodidi gr. ij [0.12] 

Iodi puri gr. 14 [0.015] 

Morph. sulph gr. % [0.01] 

01. theobromae gr. xxx [2.0] 

ty Iehthyol gr. ij [0.12] 

Potassii iodidi gr. iij [0.18] 

Morph. sulph gr. 1,4 [0.015] 

01. theobromae gr. xxx [2.0] 

IJ Bism. iodo-resorcin-sulphonatis .... gr. ij [0.12] 

Zinci oxidi gr. v [0!32] 

01. theobromae xxv [1.5] 

IJ Antipyrini gr. v [0.32] 

Sodii iodidi gr. iij [0.18] 

01. theobromae gr. xxx [2.0] 

IJ Morph. sulph gr. % [0.015] 

Ext. belladonnae gr. % [0.01] 

01. theobromae gr. xxx [2.0] 



300 GONORRHEA AND ITS COMPLICATIONS 

EPIDIDYMITIS 

Apply large gauze compresses wrung out of a hot solution 
of aluminum acetate containing some glycerin : 

If Liquoris alumini acetatis, 

Glycerini aa Jviii [250.0] 

Aquae Oj [500.0] 

M. ft. mistura. 

The compress is to be covered with oil silk and, if the pa- 
tient must be up and about, the whole put into a well fitting 
suspensory bandage. The compress should be wrung out of 
the hot solution every hour. 

A good ointment properly applied is also very beneficial. 
My favorite formula is : 
If Unguenti hydrargyri 3ii [8.0] 

Guaiacolis ' 

L aa 3j [4.0] 

Ichthyolis 

Unguenti belladonnae gss [15.0] 

Adipis benzoinati, q.s. ad gii [60.0] 

M. Sig. : Apply externally twice or three times a day. 

If Hydrargyri ammoniati 3ss [2.0] 

Methylis salicylatis 5j [4.0] 

Morphinae sulphatis gr. iv [0.25] 

Atropinae sulphatis gr. j [0.06] 

Adipis lanae gss [15.0] 

Adipis benzoinati gj [30.0] 

M. ft. ung. 



FORMULARY 301 

SUPPOSITORIES FOR GONORRHEAL PROCTITIS 

^ Protargol gr. i [0.06] 

01. theobromae gr. xx [1.3] 

M.f. suppos. No. 1. Tal. dos. No. xxx 
Sig. one t. i. d. 

Ij* Argyrol gr. v [0.3] 

01. theobromae gr. xxv [1.5] 

M.f. suppos. No. 1. Tal. dos. No. xxx 
Sig. one t. i. d. 
These may be used twice or three times a day. 

GONORRHEAL ARTHRITIS 

Rub the painful parts with an ointment consisting of 
methyl salicylate, lard and woolf at : 

^ Methyl salicylatis 3ij [8.0] 

Adipis 3iv [16.0] 

Adipis lanae 3iv [16.0] 

This is well rubbed in, covered with non-absorbent cotton 
and oiled silk or rubber tissue. The whole is held in place 
by a well fitting gauze or rubber bandage. 

Instead of the ointment I often have the joints and pain- 
ful parts painted with the following mixture : 

T$ Acidi salicylici 3j [4.0] 

Menthol gr. xv [1.0] 

Guaiacol gr. xxx [2.0] 

Alcohol gi [30.0] 

The joint is painted, then protected with non-absorbent 



302 GONORRHEA AND ITS COMPLICATIONS 

cotton, oiled silk and rubber tissue the same as after the use 
of the ointment. 

GONORRHEA IN WOMEN 

^ Aluminis giv [120.0] 

Zinci sulphatis gi [30.0] 

Cupri sulphatis . . . 3iv [15.0] 

Sig. Tablespoonful to 1 or 2 quarts of water. 

1} Protargol gr. v [0.3] 

Olei theobromae 3i [4.0] 

M. ft. suppos. ovale vel glob. No. I. 
D. tal dos. No. xij. 
Sig. One at night ; inserted high up in the vagina. 

VULVO-VAGINITIS IN LITTLE GIRLS 

5 Protargol gr. ss [0.03] 

Acidi borici gr. v [0.32] 

01. theobromae gr. xxv [1.5] 

M. f. suppos. No. 1. Tal. dos. No. xxx 
Sig. One suppository at night. 

CHANCROIDAL URETHRITIS 

ty Iodoformi gr. ij [0.12] 

01. theobromae gr. xij [0.8] 

M. f. suppos. No. 1. Tal. dos. No. xij. 
Sig. One t. i. d. 

SYPHILITIC OR CHANCRE URETHRITIS 

If Unguenti hydrargyri gr. i [0.06] 

01. theobromae gr. x [0.6] 



FORMULARY 303 

M. f. suppos. urethral. No. 1. Tal. dos. xxx 
Sig. One bis vel ter in die. 

Instead of using cacao butter alone as a base, the phar- 
macist may be instructed to add two or three grains of 
yellow wax to each suppository, so that the prescription 
would read : 

If Unguenti hydrargyri gr. j [0.06] 

Cerae flavae gr. ij [0.12] 

01. theobromae gr. x [0.6] 

M. f. suppos. urethr. No. 1. 

FOR CONDYLOMATA 

IJ Resoreinol, 

Hydrarg. chlor. mitis aa 3ij [8.0] 

M. ft. pulvis subtilis 
Sig. Apply externally. 

FOR THE PREVENTION OF GONORRHEA 

IJ Calomel 50 gm. 

Liquid petrolatum 80 c.c. 

Adeps lanae 70 gm. 

Inject a few drops into the fossa navicularis, and rub 
some of it on the glans and sulcus. 

LUBRICANTS 

^ Mercury oxycyanide 0,246 

Tragacanth 3.0 

Glycerin 20.0 

Aquae destill. steril 100.0 

(Casper) 



304 GONORRHEA AND ITS COMPLICATIONS 

Some hypersensitive urethras feel some irritation from 
the use of this lubricant. It is also a little too thick, par- 
ticularly in cold weather. I have therefore modified the 
formula, and this yields me a more satisfactory product. 
My modified formula is as follows : 

If Mercury oxycyanide 0.2 [3 grains] 

Tragacanth 2.0 [30 grains] 

Glycerin 20.0 [5 drams] 

Aquae destill. steriliz 120.0 [4. ozs.] 

Keep well covered in small, wide mouthed bottles, or have 
it filled in tin tubes. 

If Ac. salicylici gr. x [0.6] 

Olei olivae giv [120.0] 

Heat on a water bath to 100° C. for fifteen minutes, dis- 
solve the salicylic acid, cool, strain, heat again for five 
minutes and pour in sterilized bottle or container. 

In "dragging" gonorrhea and in gonorrheal and post- 
gonorrheal neuroses: 

If Elix. ferri, quinin. et strych. phosphat, |Jvj [180.0] 
S. 3i 3 times a day, in a little water, before or after 
meals. 

If Syrupi hypophosphit. compos §vi [180.0] 

S. 3i 3 times a day, in a little water, after meals. 

The above two prescriptions may look rather strange in 
a book on gonorrhea, but I have placed them here purposely 
to impress on the physician's mind the importance of pay- 



FORMULARY 305 

ing attention to the patient's general health while treating 
his gonorrhea. Many physicians are apt to forget when 
treating a certain definite condition (like gonorrhea or 
syphilis) that the patient's general condition is also of im- 
portance. On some people their gonorrhea produces a very 
depressing effect. It is possible that the gonotoxin causes 
anemia, but besides this the depressing effect of worry about 
their disease interferes with their appetite, and they often 
run down and lose flesh, etc. In such conditions it is just 
as important, perhaps more so, to give the patient tonics as 
it is to give him sandalwood internally and injections locally. 
In fact the patient's gonorrhea will often show decided im- 
provement if we stop all kinds of anti-gonorrheal treatment 
for awhile and just give him tonics, such as the compound 
syrup of hypophosphites, elixir of iron, quinine and strych- 
nine, the compound glycerophosphates, malt, malt and cod 
liver oil, etc. And where the patient develops a condition 
of neurasthenia, then the neurasthenia must be treated at the 
same time, and just as thoroughly as his gonorrhea is. 

[For the treatment of Neurasthenia see the author's 
" Treatment of Sexual Impotence and Other Sexual Dis- 
orders in Men and Women."] 

URETHRAL SUPPOSITORIES AND BOUGIES 

As will be noticed, I have not recommended any bougies 
or urethral suppositories for gonorrheal urethritis. Dozens 
of times I have given them a trial and each and every time 
I have been disappointed. It seems so plausible that 
bougies which remain in the urethra for many minutes or 
hours at a time should exert a much better effect than in- 
jections, which are immediately thrown out or remain in 



306 GONORRHEA AND ITS COMPLICATIONS 

the urethra only a few minutes at most. But unfortunately 
practice does not always corroborate theories. Theoretically 
bougies ought to be efficient, more efficient than injections, 
but practically they are not. 

Whether it is due to the fact that they act as an irritant 
or whether the vehicle (be it cocoa butter or glycerin- 
gelatin) prevents the action of the chemical agent upon 
the gonococci, making the penetrating power even much less 
than that of an aqueous solution, the fact is that bougies 
have in my hands proved much less efficient than injections, 
and sometimes they have even proved quite irritating. I 
have therefore discarded them. 

Of course it is possible that some new vehicle will be in- 
vented which will both possess penetrating power and will 
permit the chemical to remain in contact with the mucous 
membrane for a long time. Should such a vehicle be in- 
vented, then I will give the suppositories and bougies an- 
other trial. Until then I prefer to continue with aqueous 
solutions, and advise others to do the same. Still if one 
wishes to use bougies, P. D. and Co.'s Nargol bougies are 
as good as any. 

An agreeable and efficient method seems to be the incor- 
poration of the silver salts, etc., in a chondrus jelly vehicle. 
I have given such preparations [Tuboblenal, etc.] a mod- 
erate trial, but unfortunately they are not manufactured 
in this country ; and it is questionable whether they would 
in the long run prove so very much superior to aqueous solu- 
tions. 

urethral drains. The same objections that I have 
against bougies, I have, but in a still greater measure, 
against urethral drains. The pus that lies superficially on 



FORMULARY 307 

the urethral mucous membrane is very well washed away 
by urination, while the pus and gonococci that are hid- 
den in the crypts of Morgagni and the glands of Littre 
are not accessible to the " drains." And besides, all 
theoretical considerations apart, the urethra is a delicate 
tube which resents all foreign bodies, and drains are apt to 
cause considerable irritation. 



INDEX 



Abortive treatment, 119-23 
Acute prostatitis, 146-53 
Adami, on vaccines, 107 
Adenitis, 139 
Adrenalin, 145 
Agar-agar, 27 
Albargin, 51, 261 
Alcohol, 37 

injections, 78 

in chronic gonorrhea, 97, 209 
Allosan, 279 
Alum, 269 
Aluminium acetate, 57, 76 

in epididymitis, 174 
Alypin, 145, 197, 274 
Aminoform, 284 
Amphotropin, 284 
Antipyretics, 150 
Arbutin, 57, 76 
Argentamin, 261 
Argentol, 50 
Argentose, 50 
Argonin, 50-1, 262 
Argyrol, 50-51, 121, 129, 262 

deterioration of, 253 

in gonorrheal ophthalmia, 247 
Arheol, 43, 279 
Arhovin, 282 
Aristol, 84 
Arsenic iodide, in gonorrheal 

arthritis, 206 
Arthritis, gonorrheal, 202-08 

differential diagnosis of, 203-4 

treatment of, 204-8 
Asch, 176 



Aspirin, in acute prostatitis, 
150 

in epididymitis, 99, 177 
Atony of the prostate, 166 
Atropine, 143 
Atropine sulphate, 42, 57 

in gonorrheal ophthalmia, 247 
Auto-infection, 62 

Bacillus bulgaricus, in female 

gonorrhea, 228 
Balanitis, 138 
Balsamics, 41, 42, 277 
Bazy, 256 
Beer, urethral discharge from, 

89 
Belfield, 185 
Beta-eucaine, 275 
Bichloride, urethritis from, 75 
Bier's hyperemia, in gonorrheal 

arthritis, 206 
Bismarck brown, 23 
Blaschko, 127, 261 
Blenal, 279 
Borax, 47, 48 
Boric acid, 47 

in gonorrheal ophthalmia, 246 
Borovertin, 285 
Bougies, 72, 305 
Bromides, 143 
Bubo, 139 
Buller's shield, 246 
Burrow's solution, 76, 135, 140 



Calomel ointment, 130 



309 



310 



INDEX 



Calcium sulphide, in gonorrheal 

arthritis, 206 
Carbosant, 279 
Cargentos, 262 

Caruncle, urethral, in women, 251 
Casper, 120, 268, 289 
Catechu, 273 

Catheters, precautions regard- 
ing, 253 
Chancroidal urethritis, 65 
Change of air, in chronic gonor- 
rhea, 98 
Chemical urethritis, 74 
Chetwood, 179 

Chinosol, 64, 66, 135, 138, 267 
Chondrus, 289 
Chordee, 32, 57, 141 
Chronic gonorrhea, nature of, 
93-6 

case reports, 93-6 

treatment of, 97-108 

internal treatment of, 98 

length of time required to 
cure, 109 
Chronic prostatitis, 154-67 
Circumcision, 126, 136 
Cocaine hydrochloride, 274 
Coffee, 37 
Collargol, 263 

in epididymitis, 176 
Colloidal silver, 263 
Colloidal silver oxide, 262 
Colon bacillus, 28 
Complement fixation test, 28 
Condom, 127 
Condylomata acuminata, 231 

in pregnancy, 233 
Constipation, 38 

in chronic gonorrhea, 98 

in epididymitis, 177 
Conjunctivitis, metastatic gonor- 
rheal, 247 
Copaiba, 42, 280-1 

eruptions from, 250 



Copper sulphate, 102, 269 
Cowperitis, 141 
Crede, 245 
Cubebs, 42, 281 

eruptions from, 250 
Cultures, 27, 252 
Curability of gonorrhea, 15 
Cure of gonorrhea, testing for, 
79 

cessation of discharge not 
proof of, 82 
Curettage, in female gonorrhea, 

223, 230 
Cystitis, 251 

from stricture, 195 

hexamethylenamine in, 283 
Cystogen, 285 

Diathesic urethritis, 90 
Diet, in chronic prostatitis, 158 
Dilators, 103, 105, 198 
Discharge, cessation of not 
proof of cure, 82 
cessation of during epididymi- 
tis, 171 
recurrent, from patches, 253 
Drains, urethral, 306 

Electrargol, in epididymitis, 176 
Endocarditis, 250 
Endometritis, 229-30 
Endoscopic applications, 101 
Enemas, in epididymitis, 177 
Epididymitis, etiology of, 168 

exercise and, 98 

operative treatment of, 181 

recurrent, 99 

sequelae of, 180 

sterility from, 172, 182 

symptoms and course, 169-71 

treatment of, 173-82 

urethral treatment in, 178 
Erb, 15 



INDEX 



311 



Erections, imperfect, 157, 196 

painful, 141 
Ergot, 233 
Erythema, 250 
Eserine sulphate, in gonorrheal 

ophthalmia, 247 
Eucaine, 275 
Europhen, 84 
Excess, urethritis from, 91 
Extravasation of urine, 195 
Extra- venereal infection, 21-2 
Eyes, danger to, 38 

Faradization of the prostate, 

167 
Feleki's finger, 162 
Fistula, urethral, 255 
Formin, 283 
Frequency of urination, 156, 

195 * 
in women, 251-2 
Friecke, 179 
Fuchsin, 23 
Fuller, 185 

Gallic acid, 273 
General tonics, 305-6 
Glycerin, as a lubricant, 289 
Glycerin-gelatin, 27 
Gonosan, 43, 279 
Gonococcus, 23 

Gonorrhea, abortive treatment 
of, 119 

alcohol and, 37, 209 

complications of, rarer, 250 

constipation and, 38 

curability of, 15, 105, 113 

diet in, 37 

etymology of, 20 

general measures in, 36 

history of, 20 

incubation stage of, 29 

of mouth, 189 

of nose, 190 



of rectum, 187-8 

prevalence of, 15 

prevention of, 124, 216 

sexual intercourse during, 37, 
209 

social-economic conditions and, 
16, 36, 60, 105, 114, 173 

tobacco during, 209 
Gonorrhea in women, 218-32 

coitus during, 224 

curettage in, 223, 230 

diet in, 225 

incubation of, 220-1 

pregnancy and, 232-3 

prevention of, 216 

symptoms of, 221 

treatment of, 222-32 

vaccines in, 230 
Gonorrheal conjunctivitis, 247 
Gonorrheal ophthalmia, 243-9 

blindness from, 244 

etiology of, 243 

prophylaxis of, 244 

symptoms of, 245 

treatment of, 246-7 
Gram stain, 25, 26, 255 
Guiard, 129 
Guy on syringe, 100, 101 

Hamonic, 176 

Hegonon, 263 

Helmitol, 285 

Hemospermia, 183 

Hexal, 285 

Hexalet, 285 

Hexamethylenamine, 44, 198, 

283 
Hot baths, 38, 144 

in female gonorrhea, 230 
Hydrastis, 95, 273 
Hydrastin, 273 
Hydrastinine, 273 
Hydrogen peroxide, 49, 50 
Hyoscyamus, 42, 144 



312 



INDEX 



Ichthyol, 49, 50, 52, 102, 268 
suppositories in acute prosta- 
titis, 151 

Icththargan, 51, 264 

Incubation stage of gonorrhea, 
29 
in women, 220-1 

Inguinal adenitis, 139 

Injections, in acute gonorrhea, 
45-54, 252, 253 
how to take, 117 
in female gonorrhea, 226-7 

Instillations, 83, 100 

Instructions to patients, 38-9 

Internal treatment, 256 

Iodine injections and applica- 
tions, 102 
in stricture, 199 
in female gonorrhea, 226, 229 
in venereal warts, 232 
in vulvo-vaginitis, 240 

Iodine derivatives, in chemical 
urethritis, 84 

Iodoform, 66 

Irrigations, 8, 100 

Janet- Valentine irrigator, 1 00 
Janet-Frank syringe, 100, 118 

K-Y jelly, 290 

Kaolin, in vulvo-vaginitis, 241 

Kava-kava, 43 

Kava-santal, 279 

Koller, 274 

Kollmann dilators, 198 

Krameria, 273 

Lactic acid, in female gonor- 
rhea, 226 
in venereal warts, 231 
in vulvo-vaginitis, 240 

Lactosantal, 43 

Lafayette mixture, 281 

Largin, 51, 264 



Lassar, 79 

Lead acetate, 270 

Leeches, in cowperitis, 140 

in acute prostatitis, 150 
Leucorrhea, infection from, 62 

gonorrhea mistaken for, 219 
Linseed, 76 
Loeffler's solution, 24 
Lubraseptic, 290 
Lubricants, 288 
Lubrichondrin, 290 
Lugol's solution, 26 
Lupulin, 143 
Luys, 8 
Lymphangitis, 140 

Magnesium sulphate, in acute 

prostatitis, 151 
in epididymitis, 177 
Massage, prostatic, 158-63 
of seminal vesicles, 185 
over sounds, 104 
Masturbation, urethritis from, 

91 
Materia medica of gonorrhea, 

258 
Matico, 273 
Meatotomy, 199-201 
Meatus, narrow, 103, 155 
Menstruation, infection after, 

62 
urethritis from intercourse 

during, 253 
Mercurial suppositories, 68, 151 
Mercuric chloride, 49, 64, 129 
Mercuric oxycyanide, 64, 269 
Metastatic complications, 250 
Metastatic gonorrheal conjunc- 
tivitis, 247 
Metchnikoff, 130 
Methyl violet, 23 
Methylene blue, 23, 24, 25, 45, 

286 
Micrococcus catarrhalis, 25 



INDEX 



313 



Monobromated camphor, 143 
Monosodic acid phosphate, 283- 

4-6 
Morning drop, 94 
Morphine, in epididymitis, 177 
Morphine suppositories, 57, 76, 

143, 150 
Mouth, gonorrhea of the, 190 

Nargol, 51, 264 

bougies, 306 
Neisser, 20, 21 
Neoplastic urethritis, 72 
Nicolle and Blaizot, 107 
Nizin, 272 

Nose, gonorrhea of the, 190 
Novargan, 264 
Novocaine, 276 
Nutgall, 273 

Oakbark, 273 

Ober lander dilators, 198 

Ointments for epididymitis, 

175-6 
Olive oil, in chemical urethritis, 

85 
Omorol, 265 

Ophthalmia neonatorum, 243 
not always due to gonococcus, 

248 
Orchiepididymitis, 180 
Over-treatment, 256 

chronic urethritis from, 94 

Pain, at end of penis, 251 
Paraphimosis, 137 
Periurethritis, 140 
Penis clamp, 117 
Penis, pain at end of, 251 
Phenacetin, 150 
Phimosis, 134 
Phosphates in urine, 251 
Phosphaturia, 157 



Picratol, 51, 265 

Pituitary preparations, 233 

Pneumonia, urethral discharge 

during, 90 
Pollutions, in chronic gonorrhea, 
214 

in stricture, 196 
Post-gonorrheal catarrh, 94 
Potassium acetate, 76 
Potassium citrate, 56 
Potassium hydroxide, 42 
Potassium nitrate, 90 
Potassium permanganate, 49, 

58, 64, 129, 267 
Premature ejaculation, 157, 166, 

183, 196, 201 
Prevalence of gonorrhea, 14 
Prevention of gonorrhea, 124 

in women, 216 
Proctitis, gonorrheal, 187-8 
Prophylactic urethritis, '86 
Prostate, atony of the, 166 
Prostatic abscess, 152 
Prostatic massage, 158-63 
Prostatic psychrophores, 164 
Prostatitis, acute, 146-53 

chronic, 154-67 
Prostatorrhea, 166 
Protargol, 50-1, 58, 59, 121, 129, 
265 

in gonorrheal proctitis, 188 

in vulvo- vaginitis, 241 

in gonorrheal ophthalmia, 247 
Psychrophores, prostatic, 164 

in acute prostatitis, 151 
Pyemia, 250 
Pyospermia, 183 
Pyramidon, 150 

Record syringe, 118 

Rectal injections, in chronic 

prostatitis, 165 
Rectum, gonorrhea of, 187-8 
Resorcin, in venereal warts, 232 



314 



INDEX 



Resorcinol, 71 

Retention of urine, 144, 193, 

194 
Rheumatism, gonorrheal — see 

Arthritis 
Ricord, 55, 147 
Roux, 25 

Saffronin, 23 

Salicylates, in epididymitis, 177 

in gonorrheal arthritis, 205 
Salicylic acid, 135 

in venereal warts,, 231-2 
Saliformin, 285 
Salol, 99 

Salpingitis, 220, 229-30 
Sandalwood oil, 41, 42, 43, 58, 
99, 149, 277 

eruptions from, 250 
Santyl, 43, 279 
Seminal vesiculitis, 183-6 
Septicemia, 250 
Sexual intercourse, in chronic 

gonorrhea, 98 
Shreds in urine, 194, 251 
Silberol, 51 
Silver casein, 262 
Silver fluoride, 50 
Silver ichthyol, 264 
Silver iodide, 50, 261 
Silver gelatose, 261 
Silver nitrate, 50, 64, 260, 272 

endoscopic applications of, 
101 

in chronic gonorrhea, 99 

in female gonorrhea, 228-9 

irrigations and injections, 
99-101 

in ophthalmia neonatorum, 
245 

in vulvo-vaginitis, 240-1 

urethritis from, 78, 83, 94, 
120 
Silver proteid, 265 



Silver proteinate, 264 

Silver nucleid, 264 

Silver salts, 254, 260-66 

Silver vitellin, 262 

Silvol, 266 

Sinclair, 244 

Skin eruptions, 250 

Smears, how to prepare, 24 

Smoking, 38 

Sodium acid phosphate, 44, 283 

Sodium benzoate, 44, 98 

Sodium bicarbonate, 47, 48 

Sodium chloride, 47, 48 

Sophol, 266 

in ophthalmia neonatorum, 
245, 247 
Sounds, 104, 196-8 

care of, 254 

comparative scale of, 257 
Spongeitis, 140 
Stains, 23 
Staphylococcus, 28 
Sterility, following epididymitis, 
172, 182 

from vulvo-vaginitis, 238' 
Stomatitis, gonorrheal, 189 
Strangury, 31 
Stricture, 191-9 

symptoms of, 193 

treatment of, 196-9 

dilatation of, 254 

of bulbous urethra, 256 
Suppositories, in female gonor- 
rhea, 228 

for acute prostatitis, 151 

in chronic prostatitis, 165 
Syphilitic urethritis, 67 
Syringes, 116, 118 

Tannic acid, 273 

Testing the cure, 79 

Thalline sulphate, 49, 50, 52, 268 

Thymol iodide, 77, 78 

Thyresol, 43, 280 



INDEX 



315 



Tonics, general, 305-6 
Toxic urethritis, 89 
Tragacanth, 289 
Traumatic urethritis, 88 
Triticum, 76 

Tubercular urethritis, 72 
Tuberculosis of testicle, 181 
Tuboblenal, 306 

Typhoid, urethral discharge 
during, 90 

Ultzmann syringe, 101 
Unguentum Crede, in gonorrheal 

arthritis, 206 
Urethral chill, 104 
Urethral drains, 306 
Urethral suppositories, 305 
Urethritis, chancroidal, 65 

chemical, 74 

during menstruation, 253 

during pneumonia, 90 

during typhoid, 90 

from excess, 91 

from intercourse during men- 
struation, 253 

from overtreatment, 94 

from silver nitrate, 78, 83, 94, 
120 

neoplastic, 72 

post-gonorrheal, 94 

syphilitic, 67 

traumatic, 88 

toxic, 89 

tubercular, 72 
Urethroscopy, 8, 255 
Urination, frequency of, 156, 195 

frequency of in women, 251-2 

how to induce, 251 



Urine, cloudy, 251 
extravasation of, 195 
phosphates in, 157, 251 
retention of, 144, 193, 194 
shreds in, 194, 251 

Uritone, 283 

Urotropin, 44, 98, 283, 285 

Vacuum treatment, 214 
Vaccines, 106-8 

in gonorrheal arthritis, 207 

in salpingitis, 230 

in vulvo-vaginitis, 242 
Vaughan, on vaccines, 108 
Venereal warts, 71, 231-2 
Vesiculitis, 183-6 
Vesiculotomy, 185, 208 
Vulvo-vaginitis in little girls, 
22, 234-42 

etiology of, 234-6 

complications of, 237 

hastens sexual maturity, 238 

prophylaxis of, 239 

symptomatology, 236 

treatment of, 239 

Wossidlo, 8 

Yeast, in vulvo-vaginitis, 241 

Zinc acetate, 95, 271 

Zinc chloride, 271 

Zinc iodide, 271 

Zinc permanganate, 272 

Zinc sulphate, 53, 58, 77, 101-2, 

248, 271 

Zinc sulphocarbolate, 53 



A Practical Treatise on the Causes, Symptoms, and 

Treatment of 
Sexual Impotence 

And Other Sexual Disorders in Men and Women 

BY 

WILLIAM J. ROBINSON, M.D. 

Chief of the Department of Genito-Urinary Diseases and Dermatology, 

Bronx Hospital and Dispensary; Editor The American Journal 

of Urology, Venereal and Sexual Diseases; Editor and 

Founder of The Critic and Guide; Author of Sexual 

Problems of Today; Never Told Tales; 

Practical Eugenics, etc. 

BRIEF SYNOPSIS OP CONTENTS. 

Part I — 'Masturbation. Its Prevalence, Causes, Varieties, Symptoms, 
Results, Prophylaxis and Treatment. Coitus Interruptus and its 
Effects. 

Part II — Varieties, Causes and Treatment of Pollutions, Spermator- 
rhea, Prostatorrhea and Urethrorrhea. 

Part III — Sexual Impotence in the Male. Every phase of its widely 
varying causes and treatment, with illuminating case reports. 

Part IV — Sexual Neurasthenia. Causes, Treatment, case reports, 
and its relation to Impotence. 

Part V — Sterility, Male and Female. Its Causes and Treatment. 

Part VI — Sexual Disorders in Woman, Including Frigidity, Vaginis- 
mus, Adherent Clitoris, and Injuries to the Female in Coitus. 
Part VII — Priapism. Etiology, Case Reports and Treatment. 

Part VIII — Miscellaneous Topics. Including: Is Masturbation a 
Vice? — Two Kinds of Premature Ejaculation. — The Frequency of 
Coitus. — "Useless" Sexual Excitement. — The Relation Between Mental 
and Sexual Activity. — Big Families and Sexual Vigor. — Sexual Per- 
versions. 

Part IX — Prescriptions and Minor Points. 

Third edition revised and enlarged. 
Cloth bound, 422 pages. Postpaid, $3.00. 

Address: THE CRITIC AND GUIDE COMPANY 
12 MT. MORRIS PARK W., NEW YORK CITY 



THE DISOEDEES OF THE 
, SEXUAL SYSTEM 

"He who throws light on the dark and intricate 
problems of sex, helping to unravel the mysteries of 
and to cure the complex sexual disorders, does indeed 
a signal service to humanity." 

We believe that in bringing out our latest work, 
Sexual Impotence and Other Sexual Disorders in 
Men and Women, we have given the profession one 
of the most useful, one of the most valuable books that 
have ever been published. A gratifyingly large num- 
ber of physicians have told us that the book not only 
helped them to treat successfully sexual weakness and 
other disorders in their patients or in themselves, but 
that it opened their eyes to the significance of many 
things which they did not understand before. 

Those who have read the book know its value and 
importance; those who have not may be interested to 
read what the medical journals have to say about it. 
Here are a few extracts: 

No American authority has given more serious thought 
to the subject of sexual diseases than the author of this 
volume; he has given to us in it the best that in him lies. 
No physician who has had to combat this distressing condi- 
tion, and those conditions dependent upon it, has any doubt 
of its serious importance. And we all recognize the weak- 
ness of the literature on the subject. Dr. Robinson takes 



SEXUAL IMPOTENCE 

a sensible view of things which have not been sensibly con- 
sidered; nowhere has he shown this to better advantage 
than in this volume on a difficult subject. 

— Medical Fortnightly. 

Dr. Robinson discusses the numerous phases of this sub- 
ject, in both sexes, clearly and in detail. He tells no lies 
to conform to moral, social and religious ideals, and con- 
sequently those who differ with him in beliefs or in pre- 
tensions may censure him as immoral. In some of these 
points there is opportunity for difference of opinion, but 
on the whole we think that Dr. Robinson has expressed 
what the majority of physicians believe, tho not necessarily 
the opinion most frequently published. Pretty nearly 
every conceivable sexual abnormality, physical or psychic 
is at least alluded to. If we were to select any one feature 
of this work for special mention, it would be the uniform 
common sense of the author. — Buffalo Medical Journal. 

This book is not by any means a rehash of some other 
book or a resume of several. This treatise is interesting 
and valuable, and the author is absolutely honest and fear- 
less in his opinions. A unique and helpful feature is the 
case reports which illustrate every phase of sexual dis- 
order. — Indianapolis Medical Journal. 

Dr. Robinson deals with the subject in a dignified, scien- 
tific way, that will be helpful to the physician who has 
judgment enough to realize that he is as responsible for 
functions around which a modern, sham, conventional 
modesty has thrown a hiatus of folly as he is for the ap- 
petite, eliminative powers or nutritive functions of the same 
persons. And the science of eugenics can never be worthy 
of medical consideration until the people are taught that 
it is as much the duty and Dusiness of physicians to in- 
quire about the sexual habits of patients as of their habits 
of eating and drinking. This book will do much good, and 
that good will be as extensive as its reading. 

— Texas State Journal of Medicine. 



SEXUAL IMPOTENCE 

In this book we have a complete treatise on sexual dis- 
orders and their treatment, with descriptions of actual 
individual cases, giving the individual symptomatology and 
individual treatment. When given in this manner the de- 
scription becomes indelibly impressed on the memory and 
enables a physician when he gets a case to understand and 
classify it without a great amount of difficulty. 

— Charlotte Medical Journal. 

The name of the author is ample assurance that this 
treatise is not a rehash nor lacking in honest opinions fear- 
lessly expressed. The style of the writer is notably per- 
sonal, clear, straightforward and conversational. The ex- 
haustion of the first edition in less than two months from 
the day of publication shows unmistakably the need of 
a book of this character. It also shows that the profession 
is at last becoming alive to its shortcomings in the matter 
of sexual disorders and is beginning to be willing to learn. 

— Southern California Practitioner. 

Perhaps no subject pertaining to human ills has been so 
neglected by medical teachers or medical text-books as 
the subject discussed in this volume. While legitimate 
medical literature was indiscreetly silent on sex teachings, 
the quack literature was teeming with misinformation, 
which, as the author intimates, did more real harm than 
did sexual ignorance or sex abuse. The doctor will find 
this work instructive. — Illinois Medical Journal. 

As is to be expected Robinson goes into the subject 
thoroly, and calls a spade a spade, with the result that he 
has evolved a volume full of meat and of great value to 
the physician, whose ingenuity is often taxed to the ut- 
most to discover the whys and wherefores at the bottom of 
impotence. The racy Robinsonesque style adds interest to 
the text matter of the volume. — Medical Times. 

Dr. William J. Robinson is to-day the most eminent 
student of venereal disease. This fact will not need sub- 
stantiation by those who have followed his work as set 



SEXUAL IMPOTENCE 

forth in his various books. This volume is a complete 
treatise on sexual impotence. It has the merit of being a 
practical work. By this we mean it can be readily con- 
sulted and the author's meaning is always plain. Dr. Rob- 
inson is a forceful writer and his teachings are up-to-date. 
The author gives all that is new and true on the subject, 
and teaches us how to proceed in cases that we have treated 
without a complete guide in the past. No practitioner can 
afford to be without this book. — Therapeutic Record. 

The author states his views on certain mooted sexual 
questions with an unequivocal clearness and positiveness 
which certainly leaves no doubt in the reader's mind as to 
just what the author wanted to say. This is a book full of 
meat, served up in the author's frank and catchy style. 

— Medical Summary. 

In reviewing this classical work, we make unhesitatingly 
the statement that this is the only complete treatise on 
sexual impotence and other sexual disorders in the Eng- 
lish or any other language. Any physician who has made 
a careful study of the book cannot fail to treat his cases 
with a fair degree of success. It is a distinctly practical 
volume. In his inimitable style the talented author has 
woven his scientific truths into the fifty-eight chapters, 
each of which reads like an interesting novel. 

• — Pacific Medical Journal. 

The author has departed from the usual technical writ- 
ing of books. While his views may appear radical at 
times, his style is interesting, forceful, simple and yet ele- 
gant. The work is the result of the author's experience, 
of which he is easily the literary and practical master. 
It contains some new information on the nature and treat- 
ment of sexual impotence, presented in a clear, systematized 
form, therefore well adapted for the general practitioner. 

— Denver Medical Times. 

Among other phases of sexual disorders that are in- 
cluded in this volume are sterility, relation of sexual to 



SEXUAL IMPOTENCE 

mental disorders, masturbation and many other conditions 
of great importance to the patient and intense interest to 
the physician. Many case reports are given in full that 
add value to the work. Patients suffering from sexual 
disturbances present themselves to every physician, be he 
specialist or general practitioner. For this reason this 
book by Dr. Robinson appeals to the entire medical pro- 
fession. — Cincinnati Lancet -Clinic. 

Dr. Robinson has written a great deal on the sex ques- 
tion. There is a large fund of information in this book 
which should be known. The clinical phases of the subject 
have been kept in mind, the frequent reports of cases, etc., 
fill the needs of the physician. Impotence is reviewed 
from every practical standpoint. It is an entertainingly 
written volume, and gives rise to thought and study. 

— Medical Herald. 

Especially interesting are the chapters upon treatment. 
These are in every respect excellent and practical and can- 
not fail to be of service to any physician who has patients 
of this kind to treat — and who has not*? 

— American Journal of Clinical Medicine. 

The author expresses himself and his original ideas with 
the well known characteristic freedom which has given his 
editorials in The Critic and Guide such wide publicity 
and interest. — Northwest Medicine. 

Special emphasis is laid on treatment, and there are a 
number of entirely new conceptions dwelt upon. It is 
one of the most interesting clinical surveys of the subject 
ever offered to the profession. — Archives of Diagnosis. 

Dr. Robinson, the author of this book, is a specialist of 
national reputation and he is one of the most forcible 
writers in the medical profession. Such works as the one 
before us, are doing a great work in enlightening the medi- 
cal profession and thru them, the men and women of 
the country, who most need enlightenment, advice and 



SEXUAL IMPOTENCE 

treatment, upon the sex question. It is certainly a valuable 
book to the profession and contains information of in- 
estimable importance. Its careful perusal by every physi- 
cian will be the means of offering much in the way of 
valuable suggestions for the more successful and better 
management of many difficult and oftentimes misunder- 
stood cases. We must not lose sight of the large numbers 
of disorders of various kinds that may be traceable back 
to some sexual disturbance. The successful physician of 
the present time must acquaint himself with the far-reach- 
ing influence of the sex question. Certainly the successful 
management of cases of sexual impotence by the family 
physician will build up for him a reputation with the re- 
sult that he will not only be well-paid financially but will 
enjoy the lasting thanks of his patients as well. 

— Texas Medical News. 

It is an unfortunate fact that few physicians pay little 
real attention to the diagnosis and treatment of venereal 
diseases and still fewer to the sexual diseases or disorders 
that are not venereal. It is still more unfortunate that 
few physicians realize or admit their ignorance of these 
subjects. From this standpoint alone there is need of such 
a book as "Sexual Impotence," but when the book is brief, 
concise, plainly written, and very much to the point it must 
be further commended. The author wastes no time on 
anatomy, physiology, and various theories, which may be 
found in other places, but goes directly at his subject, 
devoting the most space to those things which are of the 
greatest practical importance, namely: masturbation, and 
its influence on sexual disorders, pollutions and spermator- 
rhea, sexual impotence, sexual neurasthenia, and sterility 
with its treatment. The ground covered under the above 
subjects is not only intensely interesting but immensely 
important and practical; and few men will read the book 
without some benefit. — The Journal-Lancet. 

The author is a master of his subject and has produced 
a work of exceedingly great value. It will be appreciated 



SEXUAL IMPOTENCE 

by all medical men who very frequently meet eases in- 
cluded in this category and require aid. A section on 
prescriptions gives the author's favorite methods of ex- 
hibiting certain drugs and combinations of drugs. It will 
be found a very useful book for this class of prevalent dis- 
orders. — Medical World. 

Of books on the sexual question there seems to be no 
end. This book however, we must admit, fills a sphere of 
usefulness that we cannot ascribe to many of the others. 
Dr. Robinson has taken a prominent lead in modernizing 
our present day sexual viewpoint. Many who write on 
these lines are theorists and dreamers, but Robinson's writ- 
ings stand apart by their very practicability. Thruout 
this work the needs of the physician have been kept in 
mind, and the result is a sane, sensible and useful book. 

— Medical Sentinel. 

Dr. Robinson's well-known ability in the clinical field 
of sexual deviations finds practical and scientific expression 
in this book, which is an adequate guide in the treatment 
of the sexual disorders of both men and women. 

— Medical Council. 

"We think that all readers of Dr. Robinson's book will 
be especially interested in his treatment of sterility and 
sexual neurasthenia, and we believe the work worthy of 
wide circulation among physicians. — American Practitioner. 

When the reader has completed the volume he is struck 
with the minuteness, the detail, the wealth of knowledge 
spread before him, and withal, the simple phraseology, the 
common-sense of the author and his uncommon power of 
placing before one facts, facts and yet more facts. He 
tears away the veil of mystery, sheds light on the all too 
prevailing ignorance of the medical man, specialist as well 
as general practitioner, and places in his hands means 
for the alleviation of the sufferings of many an individual 
whose ailments are but too often treated slightingly or 
not at all. — Virginia Medical Semi-Monthly, 



Sexual Problems of Today 

By WILLIAM J. ROBINSON, M. D. 

Dr. Robinson's work deals with every 
phase of the sex question, both in its in- 
dividual and its social aspects. In this 
book the scientific knowledge of a physician, 
eminent as a specialist in everything per- 
taining to the physiological and medical 
side of these topics, is combined with the 
vigorous social views of a thinker who has 
radical ideas and is not afraid to give them 
outspoken expression. 

A few of the subjects which the author 
discusses in trenchant fashion are: 

The Relations Between the Sexes and 
Man's Inhumanity to Woman. — 'The In- 
fluence of Abstinence on Man's Sexual 
Health and Sexual Power. — The Double 
Standard of Morality and the Effect of 
Continence on Each Sex. — The Limita- 
tion of Offspring-: the Most Important 
Immediate Step for the Betterment of 
the Human Race, from an Economic 
and Eugenic Standpoint. — What To Do 
With the Prostitute and How To Abol- 
ish Venereal Disease. — The Question of 
Abortion Considered In Its Ethical and 
Social Aspects. — Torturing the Wife 
When the Husband Is At Fault. — Influ- 
ence of the Prostate on Man's Mental 
Condition. — The Most Efficient Venereal 
Prophylactics, etc., etc. 

"SEXUAL PROBLEMS OF TO-DAY" will 
give most of its readers information they 
never possessed before and ideas they never 
had before—or if they had, never heard 
them publicly expressed before. 

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Never-Told Tales 

GRAPHIC STORIES OF THE DISASTROUS 
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By 

WILLIAM J. ROBINSON, M.D. 

Editor of the American Journal of Urology and of The Critic and Guide 



7* 



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